Basic Information
| Provider Information | |||||||||
| NPI: | 1629015961 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NIAGARA RADIOLOGISTS, PC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8000 | ||||||||
| Address2: | DEPT. 194 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142670002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166922160 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Practice Location | |||||||||
| Address1: | 621 10TH ST | ||||||||
| Address2: | |||||||||
| City: | NIAGARA FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 143011813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162784000 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 10/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | PERRY | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | DOCTOR IN GROUP | ||||||||
| AuthorizedOfficialTelephone: | 7162784000 | ||||||||
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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 | 2085R0202X | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00748063 | 05 | NY | MEDICAID |