Basic Information
| Provider Information | |||||||||
| NPI: | 1306852181 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREAT LAKES ANESTHESIOLOGY, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CGF ANESTHESIOLOGY ASSOCIATES, PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 MAIN ST STE K3502 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1673236570 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 818 ELLICOTT ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163236570 | ||||||||
| FaxNumber: | 7163236658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 01/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROEMER | ||||||||
| AuthorizedOfficialFirstName: | MEGAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 7163236570 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 01868253 | 05 | NY | MEDICAID |