Basic Information
| Provider Information | |||||||||
| NPI: | 1508898305 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY AT BUFFALO SURGEONS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNIVERSITY SURGICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8000 | ||||||||
| Address2: | DEPT #313 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142670002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168985227 | ||||||||
| FaxNumber: | 7168985029 | ||||||||
| Practice Location | |||||||||
| Address1: | 462 GRIDER ST | ||||||||
| Address2: | DK MILLER BLDG | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142153021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168985186 | ||||||||
| FaxNumber: | 7168985029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 01/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | DAYTON | ||||||||
| AuthorizedOfficialFirstName: | MERRIL | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7168983779 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02332410 | 05 | NY | MEDICAID |