Basic Information
| Provider Information | |||||||||
| NPI: | 1104962737 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC UROLOGY OF WESTERN NEW YORK P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 65 LEBRUN CIRCLE | ||||||||
| Address2: | |||||||||
| City: | EGGERTSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142264120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168787393 | ||||||||
| FaxNumber: | 7168787096 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HIGH ST, #C2 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168597978 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 04/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILLIOT | ||||||||
| AuthorizedOfficialFirstName: | PIERRE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7168597978 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 04/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 231942 | NY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 2088P0231X | 141541 | NY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 208800000X | 141541 | NY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 01376347 | 05 | NY | MEDICAID |