1245318278 NPI number — GREAT LAKES ORTHOPEDIC LABS, INC

Table of content: (NPI 1245318278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245318278 NPI number — GREAT LAKES ORTHOPEDIC LABS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES ORTHOPEDIC LABS, INC
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:
Provider Other Organization Name Type Code:
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:
1245318278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1031 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUFFALO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14203-1014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-893-4116
Provider Business Mailing Address Fax Number:
716-897-2110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1031 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14203-1014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-893-4116
Provider Business Practice Location Address Fax Number:
716-897-2110
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DALEY
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
J
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
716-893-4116

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00011212601 . This is a "UNIVERA HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000551033001 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 16146 . This is a "MOLINA HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 040401000151 . This is a "FIDELIS CARE NEW YORK" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 8207649 . This is a "INDEPENDENT HEALTH ASSOCI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com