Basic Information
| Provider Information | |||||||||
| NPI: | 1063790608 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN NEW YORK MEDICAL PRACTICE P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1425 PORTLAND AVE | ||||||||
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| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146213001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859221318 | ||||||||
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| Address1: | 1425 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146213001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859221318 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2011 | ||||||||
| LastUpdateDate: | 05/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | TINCH | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP- FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5859221223 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207LP2900X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03406397 | 05 | NY | MEDICAID |