Basic Information
Provider Information | |||||||||
NPI: | 1063470003 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCGORRAY | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | K | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6255 SHERIDAN DR | ||||||||
Address2: | SUITE 304 | ||||||||
City: | WILLIAMSVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 142214836 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7168578666 | ||||||||
FaxNumber: | 7168578944 | ||||||||
Practice Location | |||||||||
Address1: | 295 ESSJAY RD | ||||||||
Address2: |   | ||||||||
City: | WILLIAMSVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 142218216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7166301159 | ||||||||
FaxNumber: | 7162505950 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2006 | ||||||||
LastUpdateDate: | 04/24/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 192032-1 | NY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 000523035004 | 01 | NY | HEALTH NOW | OTHER | 110170246 | 01 | NY | RR MEDICARE | OTHER | 00010114501 | 01 | NY | UNIVERA | OTHER | 01481938 | 05 | NY |   | MEDICAID | 0405585 | 01 | NY | IHA | OTHER | 161000580 | 01 | NY | EMPIRE | OTHER | 161000580 | 01 | NY | NOVA | OTHER | 161000580 | 01 | NY | NORTH AMERICAN PREFERRED | OTHER | 161000580 | 01 | NY | AETNA | OTHER | 192032-1W | 01 | NY | WORKERS COMPENATION | OTHER |