Provider Demographics
NPI:1801074539
Name:WESTERN NEW YORK IIMMEDIATE MEDICAL CARE, LLC
Entity type:Organization
Organization Name:WESTERN NEW YORK IIMMEDIATE MEDICAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-564-2273
Mailing Address - Street 1:PO BOX 5101
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14240-5101
Mailing Address - Country:US
Mailing Address - Phone:716-692-3302
Mailing Address - Fax:716-362-9518
Practice Address - Street 1:2099 NIAGARA FALLS BLVD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14228-3518
Practice Address - Country:US
Practice Address - Phone:716-564-2273
Practice Address - Fax:716-564-2272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY159276207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0584Medicare PIN