Basic Information
| Provider Information | |||||||||
| NPI: | 1013168194 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUFFALO ULTRASOUND, IDTF | ||||||||
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| Mailing Information | |||||||||
| Address1: | 388 EVANS ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166312262 | ||||||||
| FaxNumber: | 7166318237 | ||||||||
| Practice Location | |||||||||
| Address1: | 388 EVANS ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166312262 | ||||||||
| FaxNumber: | 7166318237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2008 | ||||||||
| LastUpdateDate: | 04/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | STRAECK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7166312262 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0208X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mobile | 335V00000X | Y | Suppliers | Portable X-Ray Supplier |
ID Information
| ID | Type | State | Issuer | Description | 02405181 | 05 | NY | MEDICAID |