Basic Information
Provider Information | |||||||||
NPI: | 1326158593 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HIGHGATE MEDICAL GROUP, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1150 YOUNGS RD | ||||||||
Address2: | SUITE 104 | ||||||||
City: | WILLIAMSVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 142218053 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7166367979 | ||||||||
FaxNumber: | 7166367993 | ||||||||
Practice Location | |||||||||
Address1: | 1150 YOUNGS RD | ||||||||
Address2: | SUITE 104 | ||||||||
City: | WILLIAMSVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 142218053 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7166367979 | ||||||||
FaxNumber: | 7166367993 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2006 | ||||||||
LastUpdateDate: | 01/12/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BODKIN | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7166367979 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: | II | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 131001 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 01483930 | 05 | NY |   | MEDICAID | A30001607 | 01 | NY | MEDICARE | OTHER |