Provider Demographics
NPI:1811449697
Name:WEST CAYUGA MEDICINE PC
Entity type:Organization
Organization Name:WEST CAYUGA MEDICINE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER & CEO
Authorized Official - Prefix:
Authorized Official - First Name:FABIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:VENGOECHEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-368-6953
Mailing Address - Street 1:257 W CAYUGA ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-2439
Mailing Address - Country:US
Mailing Address - Phone:267-368-6953
Mailing Address - Fax:215-621-6940
Practice Address - Street 1:257 W CAYUGA ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-2439
Practice Address - Country:US
Practice Address - Phone:267-368-6953
Practice Address - Fax:215-621-6940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-27
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103229169Medicaid
PA543812Medicare PIN