Basic Information
| Provider Information | |||||||||
| NPI: | 1306829825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERR | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4511 HARLEM ROAD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142263822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168396720 | ||||||||
| FaxNumber: | 7168396740 | ||||||||
| Practice Location | |||||||||
| Address1: | 219 BRYANT STREET | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142222006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 10/29/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 41240 | CO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 2080P0204X | 207008 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01760392 | 05 | NY | MEDICAID | 00010308401 | 01 | UNIVERA | OTHER | 071031000079 | 01 | FIDELIS | OTHER | 3909473 | 01 | IHA | OTHER | 77220561 | 05 | CO | MEDICAID | 000524879001 | 01 | BC/BS | OTHER |