Provider Demographics
NPI:1669422697
Name:EASTERN NIAGARA OB/GYN, PC
Entity type:Organization
Organization Name:EASTERN NIAGARA OB/GYN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:G
Authorized Official - Last Name:JAMMAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-433-1941
Mailing Address - Street 1:175 WALNUT ST.
Mailing Address - Street 2:SUITE 7
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-3775
Mailing Address - Country:US
Mailing Address - Phone:716-433-1941
Mailing Address - Fax:716-439-1233
Practice Address - Street 1:175 WALNUT ST.
Practice Address - Street 2:SUITE 7
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-3775
Practice Address - Country:US
Practice Address - Phone:716-433-1941
Practice Address - Fax:716-439-1233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00929593Medicaid
NY000933Medicare ID - Type Unspecified
NY00933Medicare UPIN