Basic Information
| Provider Information | |||||||||
| NPI: | 1346446614 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHTOWNS NEUROLOGY OF WESTERN NEW YORK PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3775 SENECA ST | ||||||||
| Address2: | |||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142243434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167120890 | ||||||||
| FaxNumber: | 7167120933 | ||||||||
| Practice Location | |||||||||
| Address1: | 3775 SENECA ST | ||||||||
| Address2: | |||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142243434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167120890 | ||||||||
| FaxNumber: | 7167120933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 10/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | LEEKWEN | ||||||||
| AuthorizedOfficialFirstName: | PETERKIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7167120890 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 206950 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 02731060 | 05 | NY | MEDICAID |