Basic Information
| Provider Information | |||||||||
| NPI: | 1093394983 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN NEW YORK MEDICAL PRACTICE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 KINGS HWY S | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146175504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859221900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1445 PORTLAND AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146213008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852662010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2021 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | HOLDER | ||||||||
| AuthorizedOfficialFirstName: | NICHOLE | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PAYER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 5859220293 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WESTERN NEW YORK MEDICAL PRACTICE, P.C. | ||||||||
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| NPICertificationDate: | 04/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.