Basic Information
| Provider Information | |||||||||
| NPI: | 1487601837 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ERIE COUNTY SOUTH EAST CORP V | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPECTRUM HUMAN SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 227 THORN AVE | ||||||||
| Address2: | |||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141272600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166622040 | ||||||||
| FaxNumber: | 7166620019 | ||||||||
| Practice Location | |||||||||
| Address1: | 326 ORCHARD PARK RD | ||||||||
| Address2: | |||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142242635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166626638 | ||||||||
| FaxNumber: | 7168230751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 07/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | NISBET | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7166622040 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 6845102D | NY | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0001122770 | 01 | NY | UNIVERA MH | OTHER | 040727000154 | 01 | NY | MED.MANCARE MH & CD | OTHER | 000507634001 | 01 | NY | BCBS - MH | OTHER | 8401220 | 01 | NY | IHA - MH & CD | OTHER | 00660577 | 05 | NY | MEDICAID |