Basic Information
| Provider Information | |||||||||
| NPI: | 1942247358 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL EMERGENCY SERVICES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 FOUNTAIN PLZ | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142022211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166918838 | ||||||||
| FaxNumber: | 7165641134 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 FOUNTAIN PLZ | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142022211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166918838 | ||||||||
| FaxNumber: | 7165641134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 08/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | PUNDT | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7165801801 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000005133161 | 01 | NY | BLUE CROSS BLUE SHIELD | OTHER |