Basic Information
| Provider Information | |||||||||
| NPI: | 1588743702 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY PSYCHIATRIC PRACTICE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 462 GRIDER ST | ||||||||
| Address2: | ECMC, ROOM 1168 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142153021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168984535 | ||||||||
| FaxNumber: | 7168984447 | ||||||||
| Practice Location | |||||||||
| Address1: | 462 GRIDER ST | ||||||||
| Address2: | ECMC, ROOM 1168 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142153021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168984535 | ||||||||
| FaxNumber: | 7168984447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CAVARETTA | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7168984535 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 01398338 | 05 | NY | MEDICAID |