1780839886 NPI number — DALE WARREN SPONAUGLE, MD, PC

Table of content: (NPI 1780839886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780839886 NPI number — DALE WARREN SPONAUGLE, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DALE WARREN SPONAUGLE, MD, PC
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:
1780839886
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
908 NIAGARA FALLS BLVD
Provider Second Line Business Mailing Address:
STE 208
Provider Business Mailing Address City Name:
N TONAWANDA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14120-2019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-692-3302
Provider Business Mailing Address Fax Number:
716-692-4342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 OHIO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDINA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14103-1063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-798-8054
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SPONAUGLE
Authorized Official First Name:
DALE
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
585-798-8054

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  164356 , 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: 01257134 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000525331009 . This is a "BLUE CROSS OF WNY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5690902 . This is a "IHA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00020548502 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 9600955 . This is a "GHI - PPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P010164356 . This is a "BLUE CHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 040426004344 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com