Provider Demographics
NPI:1134257892
Name:CLARENCE CARDIOLOGY LLC
Entity type:Organization
Organization Name:CLARENCE CARDIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-887-4093
Mailing Address - Street 1:207 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14228-2302
Mailing Address - Country:US
Mailing Address - Phone:716-689-1901
Mailing Address - Fax:
Practice Address - Street 1:9095 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARENCE
Practice Address - State:NY
Practice Address - Zip Code:14031-1967
Practice Address - Country:US
Practice Address - Phone:716-887-4093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA1628Medicare ID - Type UnspecifiedGROUP MC NUMBER