Healthcare Provider Details

I. General information

NPI: 1053733915
Provider Name (Legal Business Name): PHYSICIANS PRACTICE OF EASTERN NIAGARA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2014
Last Update Date: 01/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 ELIZABETH DR
LOCKPORT NY
14094-5226
US

IV. Provider business mailing address

908 NIAGARA FALLS BLVD SUITE 208
NORTH TONAWANDA NY
14120-2019
US

V. Phone/Fax

Practice location:
  • Phone: 716-692-3302
  • Fax: 716-213-0935
Mailing address:
  • Phone: 716-692-2160
  • Fax: 716-213-0935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL ICKOWSKI
Title or Position: CFO
Credential:
Phone: 716-514-5501