Basic Information
| Provider Information | |||||||||
| NPI: | 1104281195 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUFFALO MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PODIATRY AFFILIATES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 ESSJAY RD STE 170 | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166301219 | ||||||||
| FaxNumber: | 7168171726 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166301295 | ||||||||
| FaxNumber: | 7162505999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2015 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | SCULLY | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7166302500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N006292 | NY | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.