Healthcare Provider Details

I. General information

NPI: 1942202726
Provider Name (Legal Business Name): BRIAN M EDELSTEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MAIN ST FL 4
BUFFALO NY
14203-1009
US

IV. Provider business mailing address

1001 MAIN ST FL 5
BUFFALO NY
14203-1009
US

V. Phone/Fax

Practice location:
  • Phone: 716-323-0080
  • Fax:
Mailing address:
  • Phone: 716-323-0080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number036-081942
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number299601
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: