Basic Information
| Provider Information | |||||||||
| NPI: | 1427130889 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | M A STUTZMAN ADDICTION TREATMENT CENTER | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 360 FOREST AVENUE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142131298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168824900 | ||||||||
| FaxNumber: | 7168824426 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 FOREST AVENUE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142131298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168824900 | ||||||||
| FaxNumber: | 7168824426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LAWLER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSOCIATE COMMISSIONER DIVISION OF | ||||||||
| AuthorizedOfficialTelephone: | 5184575312 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | NY | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 01423394 | 05 | NY | MEDICAID |