1922181767 NPI number — CHAUTAUQUA MEDICAL PRACTICE, P.C.

Table of content: (NPI 1922181767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922181767 NPI number — CHAUTAUQUA MEDICAL PRACTICE, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHAUTAUQUA MEDICAL PRACTICE, P.C.
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:
CHAUTAUQUA MEDICAL PRACTICE, P.C.
Provider Other Organization Name Type Code:
3
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:
1922181767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 470
Provider Second Line Business Mailing Address:
4936 MAIN ST
Provider Business Mailing Address City Name:
BEMUS POINT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-386-2414
Provider Business Mailing Address Fax Number:
716-386-2437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4936 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEMUS POINT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-386-2414
Provider Business Practice Location Address Fax Number:
716-386-2437
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLEY
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
716-386-2414

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  204064 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01669929 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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