Provider Demographics
NPI:1124292099
Name:JOHN A. BRACH, MD, PC
Entity type:Organization
Organization Name:JOHN A. BRACH, MD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-383-5450
Mailing Address - Street 1:11178 JAMISON RD
Mailing Address - Street 2:
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-9635
Mailing Address - Country:US
Mailing Address - Phone:716-662-2544
Mailing Address - Fax:
Practice Address - Street 1:ROSWELL PARK CANCER INSTITUTE
Practice Address - Street 2:ELM AND CARLTON ST
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14263-0001
Practice Address - Country:US
Practice Address - Phone:716-713-6808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02551797Medicaid
NY000513219100OtherBSWNY
NY02551797Medicaid