Basic Information
Provider Information | |||||||||
NPI: | 1043295843 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VARGO | ||||||||
FirstName: | EDWARD | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | RPAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 550 ORCHARD PARK RD | ||||||||
Address2: | STE A105 | ||||||||
City: | WEST SENECA | ||||||||
State: | NY | ||||||||
PostalCode: | 142242646 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7166776000 | ||||||||
FaxNumber: | 7166776006 | ||||||||
Practice Location | |||||||||
Address1: | 550 ORCHARD PARK RD | ||||||||
Address2: | STE A105 | ||||||||
City: | WEST SENECA | ||||||||
State: | NY | ||||||||
PostalCode: | 142242646 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7166776000 | ||||||||
FaxNumber: | 7166776006 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/14/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 0069691 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 00026502301 | 01 | NY | UNIVERA HEALTHCARE | OTHER | 000570211001 | 01 | NY | BLUE CROSS BLUE SHIELD | OTHER | 01998627 | 05 | NY |   | MEDICAID | 9512129 | 01 | NY | INDEPENDENT HEALTH | OTHER |