Basic Information
| Provider Information | |||||||||
| NPI: | 1992827729 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JUNIPER RADIOLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1314 | ||||||||
| Address2: | |||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141278314 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 224 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141411443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165922871 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 04/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | FENZL | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7166491722 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GRP529117001 | 01 | NY | BCBS WESTERN NY | OTHER | 02872008 | 05 | NY | MEDICAID |