Basic Information
| Provider Information | |||||||||
| NPI: | 1326133620 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DR. MARIA JEREVA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD | ||||||||
| Address2: | STE. 208 | ||||||||
| City: | N. TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 GRAND ISLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167738925 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 05/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | JEREVA-SIMONOVA | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7167738925 | ||||||||
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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 | 207Q00000X | 239958 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02080115 | 05 | NY | MEDICAID |