Provider Demographics
NPI:1255419594
Name:NIAGARA UROLOGY ASSOCIATES PC
Entity type:Organization
Organization Name:NIAGARA UROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHAIRAT
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTSUNTURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-285-3464
Mailing Address - Street 1:1 COLOMBA DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14305-1205
Mailing Address - Country:US
Mailing Address - Phone:716-285-3464
Mailing Address - Fax:716-285-8520
Practice Address - Street 1:1 COLOMBA DR
Practice Address - Street 2:SUITE 2
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14305-1205
Practice Address - Country:US
Practice Address - Phone:716-285-3464
Practice Address - Fax:716-285-8520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYGRP506680001OtherBLUE CROSS BLUE SHIELD
NY009353099OtherGHI
NY0111170OtherFIDELIS
NY33D0681581OtherCLIA#
NY009353099OtherGHI
NY0111170OtherFIDELIS