Basic Information
| Provider Information | |||||||||
| NPI: | 1750680609 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JULIE A GAVIN MD OBGYN PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD | ||||||||
| Address2: | STE 208 | ||||||||
| City: | N TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7163323525 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | KENMORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142171094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7169132297 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2011 | ||||||||
| LastUpdateDate: | 03/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | GAVIN | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7169132297 | ||||||||
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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 | 207V00000X | 243652 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 02893401 | 05 | NY | MEDICAID | 0714301 | 01 | NY | IHA | OTHER |