Basic Information
| Provider Information | |||||||||
| NPI: | 1649232059 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FITZGERALD | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3040 AMSDELL RD | ||||||||
| Address2: | |||||||||
| City: | HAMBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140755835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166499000 | ||||||||
| FaxNumber: | 7166499005 | ||||||||
| Practice Location | |||||||||
| Address1: | 565 ABBOTT RD | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142202039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168282399 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 09/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | 218039 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 218039 | NY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000528130001 | 01 | NY | BCBS | OTHER | 1609206 | 01 | NY | INDEPENDENT HEALTH | OTHER | P00257184 | 01 | NY | RR MEDICARE | OTHER | 00027170405 | 01 | NY | UNIVERA HEALTHCARE | OTHER | 02648786 | 05 | NY | MEDICAID | 050709000020 | 01 | NY | FIDELIS CARE OF NEW YORK | OTHER | 190443FF | 01 | NY | PREFERRED CARE | OTHER |