1821076308 NPI number — ELITE MEDICAL SUPPLY

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 1821076308 NPI number — ELITE MEDICAL SUPPLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE MEDICAL SUPPLY
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:
1821076308
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST SENECA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14224-3332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-712-0881
Provider Business Mailing Address Fax Number:
716-712-0882

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST SENECA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14224-3332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-712-0881
Provider Business Practice Location Address Fax Number:
716-712-0882
Provider Enumeration Date:
01/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NIKIEL
Authorized Official First Name:
GARY
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
716-712-0881

Provider Taxonomy Codes

  • Taxonomy code: 225000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000551490001 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 02752078 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8290875 . This is a "INDEPENDENT HEALTH" identifier . This identifiers is of the category "OTHER".




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