Basic Information
| Provider Information | |||||||||
| NPI: | 1184664963 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NIAGARA HOSPITALIST, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ENDION HOSPITALIST OF WILLIAMSVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 435 | ||||||||
| Address2: | 428 CLIFTON CORPORATE PARK | ||||||||
| City: | CLIFTON PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120650435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183835450 | ||||||||
| FaxNumber: | 5183834223 | ||||||||
| Practice Location | |||||||||
| Address1: | 1540 MAPLE RD | ||||||||
| Address2: | @MILLARD FILLMORE SUBURBAN HOSPITAL | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142213647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162983782 | ||||||||
| FaxNumber: | 5183834223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 11/14/2007 | ||||||||
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| AuthorizedOfficialLastName: | BRACH | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5183835450 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 02656839 | 05 | NY | MEDICAID |