Basic Information
| Provider Information | |||||||||
| NPI: | 1225222177 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BUFFALO ENDOVASCULAR AND VASCULAR SURGICAL ASSOCIATES, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD | ||||||||
| Address2: | STE 208 | ||||||||
| City: | N TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HIGH ST | ||||||||
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| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168595600 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2007 | ||||||||
| LastUpdateDate: | 09/04/2007 | ||||||||
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| AuthorizedOfficialLastName: | NOOR | ||||||||
| AuthorizedOfficialFirstName: | SONYA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7166922160 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 231335 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02247354 | 05 | NY | MEDICAID |