Healthcare Provider Details

I. General information

NPI: 1871020602
Provider Name (Legal Business Name): GREATER BUFFALO UNITED ACCOUNTABLE CARE ORGANIZATION,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 NIAGARA ST REAR
BUFFALO NY
14201-1108
US

IV. Provider business mailing address

229 W GENESEE ST PO BOX 877
BUFFALO NY
14201-7099
US

V. Phone/Fax

Practice location:
  • Phone: 716-247-5282
  • Fax: 716-884-8096
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number185052
License Number StateNY

VIII. Authorized Official

Name: DR. RAUL VAZQUEZ
Title or Position: CEO
Credential: M.D.
Phone: 716-830-4840