1033263504 NPI number — AMHERST NEUROLOGIC ASSOCIATES

Table of content: (NPI 1033263504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033263504 NPI number — AMHERST NEUROLOGIC ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMHERST NEUROLOGIC ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SVEND GOTHGEN MD
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033263504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4140 SHERIDAN DRIVE
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
WILLIAMSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14221-4341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-634-2652
Provider Business Mailing Address Fax Number:
716-634-2653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4140 SHERIDAN DRIVE
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
WILLIAMSVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14221-4341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-634-2652
Provider Business Practice Location Address Fax Number:
716-634-2653
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOTHGEN
Authorized Official First Name:
SVEND
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
716-634-2652

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  136790 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00010066701 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000507660001 . This is a "BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0501229 . This is a "INDEPENDENT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00619076 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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