Basic Information
| Provider Information | |||||||||
| NPI: | 1982662565 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCOY | ||||||||
| FirstName: | WAYMAN | ||||||||
| MiddleName: | CORNELIUS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 GARDENVILLE PKWY W | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142241324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168576150 | ||||||||
| FaxNumber: | 7166564074 | ||||||||
| Practice Location | |||||||||
| Address1: | 899 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168782700 | ||||||||
| FaxNumber: | 7165045544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 01/11/2010 | ||||||||
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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 | 208000000X | 084827 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00010113803 | 01 | NY | UNIVERA # | OTHER | 000503171006 | 01 | NY | HEALTH NOW BCBS # | OTHER | 159894DL | 01 | NY | PREFERRED CARE # | OTHER | 040426000155 | 01 | NY | FIDELIS CARE # | OTHER | 1200515 | 01 | NY | IHA # | OTHER |