Healthcare Provider Details

I. General information

NPI: 1922181767
Provider Name (Legal Business Name): CHAUTAUQUA MEDICAL PRACTICE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4936 MAIN ST
BEMUS POINT NY
14712
US

IV. Provider business mailing address

PO BOX 470 4936 MAIN ST
BEMUS POINT NY
14712
US

V. Phone/Fax

Practice location:
  • Phone: 716-386-2414
  • Fax: 716-386-2437
Mailing address:
  • Phone: 716-386-2414
  • Fax: 716-386-2437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number204064
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL S HOLLEY
Title or Position: MD
Credential:
Phone: 716-386-2414