Basic Information
| Provider Information | |||||||||
| NPI: | 1285682500 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN NEW YORK RADIOLOGY ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 199 PARK CLUB LN STE 300 | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168364646 | ||||||||
| FaxNumber: | 7168364696 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168592954 | ||||||||
| FaxNumber: | 7168592962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 12/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | PEARSEN | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 7168592954 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | DA0528 | 01 | RR MEDICARE | OTHER | 02383255 | 05 | NY | MEDICAID |