Basic Information
| Provider Information | |||||||||
| NPI: | 1538390505 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANCER CARE OF WESTERN NEW YORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | WESTERN NEW YORK UROLOGY ASSOC., LLC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 117 FOOTE AVENUE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163389500 | ||||||||
| FaxNumber: | 7163389550 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 FOOTE AVENUE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163389500 | ||||||||
| FaxNumber: | 7163389550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2009 | ||||||||
| LastUpdateDate: | 08/07/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRECO | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7168445600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WESTERN NEW YORK UROLOGY ASSOCIATES, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 2085R0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.