Basic Information
| Provider Information | |||||||||
| NPI: | 1790892826 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BUFFALO ULTRASOUND, IDTF INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 388 EVANS STREET | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166348800 | ||||||||
| FaxNumber: | 7166348987 | ||||||||
| Practice Location | |||||||||
| Address1: | 388 EVANS ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166312262 | ||||||||
| FaxNumber: | 7166312317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 11/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | STRAECK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7166312262 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471B0102X | NY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Bone Densitometry | 2471C3402X | NY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Radiography | 2471S1302X | NY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Sonography | 261QR0208X | NY | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mobile | 2471V0105X | NY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Vascular Sonography |
ID Information
| ID | Type | State | Issuer | Description | 02405181 | 05 | NY | MEDICAID | 4100574 | 01 | NY | GHI | OTHER | 470000919 | 01 | NY | RAILROAD MEDICARE | OTHER | 0051047011 | 01 | NY | BC/BS WNY | OTHER | 630001671 | 01 | NY | RAILROAD MEDICARE | OTHER | P010169198 | 01 | NY | BC/BS ROCHESTER | OTHER | 00011172401 | 01 | NY | UNIVERA | OTHER | 1610947 | 01 | NY | INDEPENDENT HEALTH | OTHER |