Basic Information
| Provider Information | |||||||||
| NPI: | 1659310092 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES PHYSICIAN, PC | ||||||||
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| OtherOrganizationName: | WESTERN NEW YORK UROLOGY ASSOCIATES LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3085 HARLEM RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142252591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168445000 | ||||||||
| FaxNumber: | 7168445050 | ||||||||
| Practice Location | |||||||||
| Address1: | 3085 HARLEM RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142252591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168445000 | ||||||||
| FaxNumber: | 7168445050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | CHEVLI | ||||||||
| AuthorizedOfficialFirstName: | KAIRAV | ||||||||
| AuthorizedOfficialMiddleName: | KENT | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7168445000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 2085R0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 208800000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 03869087 | 05 | NY | MEDICAID |