Basic Information
| Provider Information | |||||||||
| NPI: | 1598830218 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN NEW YORK DC, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ORCHARD PARK DIALYSIS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2100 CENTRAL AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803012838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037857523 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3801 TAYLOR RD | ||||||||
| Address2: | |||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141272232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162097200 | ||||||||
| FaxNumber: | 7162097206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAWSON | ||||||||
| AuthorizedOfficialFirstName: | HERBERT | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3037857521 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 1401229R | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 01984981 | 05 | NY | MEDICAID | 000000378002 | 01 | NY | BLUE CROSS PROVIDER NUMBE | OTHER | 2V | 01 | NY | INDEPENDENT HEALTH | OTHER |