Healthcare Provider Details

I. General information

NPI: 1720045792
Provider Name (Legal Business Name): GREAT LAKES PHYSICIAN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3085 HARLEM RD SUITE 350
CHEEKTOWAGA NY
14225-2591
US

IV. Provider business mailing address

3085 HARLEM RD SUITE 350
CHEEKTOWAGA NY
14225-2591
US

V. Phone/Fax

Practice location:
  • Phone: 716-844-5000
  • Fax: 716-844-5050
Mailing address:
  • Phone: 716-844-5000
  • Fax: 716-844-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: K KENT CHEVLI
Title or Position: MANAGING PHYSICIAN
Credential: M.D.
Phone: 716-844-5600