Healthcare Provider Details

I. General information

NPI: 1063790608
Provider Name (Legal Business Name): WESTERN NEW YORK MEDICAL PRACTICE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE
ROCHESTER NY
14621-3001
US

IV. Provider business mailing address

1425 PORTLAND AVE
ROCHESTER NY
14621-3001
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-1318
  • Fax:
Mailing address:
  • Phone: 585-922-1318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: PAULA TINCH
Title or Position: SVP- FINANCE
Credential:
Phone: 585-922-1223