Basic Information
| Provider Information | |||||||||
| NPI: | 1891906962 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESEE VALLEY GROUP HEALTH ASSOCIATION | ||||||||
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| OtherOrganizationName: | LIFETIME HEALTH MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 EMPIRE DR | ||||||||
| Address2: | |||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142241320 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 EMPIRE DR | ||||||||
| Address2: | |||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142241320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166686170 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CARLASCIO | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT REGIONAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5853381400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | DC7264 | 01 | NY | MEDICARE RAILROAD GROUP # | OTHER |