Basic Information
| Provider Information | |||||||||
| NPI: | 1780839886 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DALE WARREN SPONAUGLE, MD, PC | ||||||||
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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: | 7166924342 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 OHIO ST | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141031063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857988054 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2008 | ||||||||
| LastUpdateDate: | 11/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | SPONAUGLE | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5857988054 | ||||||||
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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 | 164356 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 01257134 | 05 | NY | MEDICAID | 000525331009 | 01 | NY | BLUE CROSS OF WNY | OTHER | 5690902 | 01 | NY | IHA | OTHER | 00020548502 | 01 | NY | UNIVERA | OTHER | 9600955 | 01 | NY | GHI - PPO | OTHER | P010164356 | 01 | NY | BLUE CHOICE | OTHER | 040426004344 | 01 | NY | FIDELIS | OTHER |