Healthcare Provider Details

I. General information

NPI: 1548354335
Provider Name (Legal Business Name): EMG SPINE AND SPORTS MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 01/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 MEAD ST
NORTH TONAWANDA NY
14120-4435
US

IV. Provider business mailing address

338 HARRIS HILL ROAD SUITE 207
WILLIAMSVILLE NY
14221
US

V. Phone/Fax

Practice location:
  • Phone: 716-692-4020
  • Fax: 716-692-5090
Mailing address:
  • Phone: 716-634-4798
  • Fax: 716-634-0987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number236351-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number236351
License Number StateNY

VIII. Authorized Official

Name: DR. TAHIR M QAZI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 716-692-4020