1447351259 NPI number — PAIN MANAGEMENT AND HEADACHE MEDICINE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447351259 NPI number — PAIN MANAGEMENT AND HEADACHE MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT AND HEADACHE MEDICINE
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:
1447351259
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
338 HARRIS HILL RD
Provider Second Line Business Mailing Address:
SUITE 207
Provider Business Mailing Address City Name:
WILLIAMSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14221-7407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-634-4798
Provider Business Mailing Address Fax Number:
716-634-0987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2121 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14214-2693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-832-1107
Provider Business Practice Location Address Fax Number:
716-832-1108
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HENRY
Authorized Official First Name:
ASHRAF
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
716-634-4798

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  236106 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 236106 , 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: 03188305 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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