Healthcare Provider Details

I. General information

NPI: 1851824551
Provider Name (Legal Business Name): PHILLIP MACLEOD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 PROSPECT AVE
EAST AURORA NY
14052-2215
US

IV. Provider business mailing address

309 PROSPECT AVE
EAST AURORA NY
14052-2215
US

V. Phone/Fax

Practice location:
  • Phone: 716-982-6226
  • Fax:
Mailing address:
  • Phone: 716-982-6226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: