Healthcare Provider Details

I. General information

NPI: 1336229509
Provider Name (Legal Business Name): GEBHARD MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 ELMWOOD AVE
KENMORE NY
14217-1304
US

IV. Provider business mailing address

40 CARDINAL LN
GRAND ISLAND NY
14072-1950
US

V. Phone/Fax

Practice location:
  • Phone: 716-649-0887
  • Fax: 716-646-4611
Mailing address:
  • Phone: 716-649-0887
  • Fax: 716-646-4611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number176365
License Number StateNY

VIII. Authorized Official

Name: ROBERTA E GEBHARD
Title or Position: OWNER PHYSICIAN
Credential: D.O.
Phone: 716-649-0887