Basic Information
| Provider Information | |||||||||
| NPI: | 1467409870 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUTERMAN | ||||||||
| FirstName: | MAYNARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6653 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162044500 | ||||||||
| FaxNumber: | 7162044501 | ||||||||
| Practice Location | |||||||||
| Address1: | 3669 SOUTHWESTERN BLVD | ||||||||
| Address2: | |||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141271732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162044500 | ||||||||
| FaxNumber: | 7162044501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 11/05/2007 | ||||||||
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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 | 207PE0004X | 221351-1 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 02192905 | 05 | NY | MEDICAID |