1578526240 NPI number — CORY EGAN DNP

Table of content: CORY EGAN DNP (NPI 1578526240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578526240 NPI number — CORY EGAN DNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EGAN
Provider First Name:
CORY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DNP
Provider Gender Code:
F

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:
1578526240
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 LA RIVIERE DR STE 201
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:
14202-4344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-893-1010
Provider Business Mailing Address Fax Number:
716-893-1002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 LA RIVIERE DR STE 201
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:
14202-4344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-893-1010
Provider Business Practice Location Address Fax Number:
716-893-1010
Provider Enumeration Date:
04/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  F333122 , 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: 041104000132 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 9512540 . This is a "IHA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000560586005 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00026535201 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000560586003 . This is a "BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02345251 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00026921002 . This is a "UNIVERA" identifier . This identifiers is of the category "OTHER".




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