Healthcare Provider Details

I. General information

NPI: 1679684625
Provider Name (Legal Business Name): SHERIDAN DRIVE MEDICAL GROUP LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1491 SHERIDAN DR
TONAWANDA NY
14217-1234
US

IV. Provider business mailing address

1491 SHERIDAN DR
TONAWANDA NY
14217-1234
US

V. Phone/Fax

Practice location:
  • Phone: 716-332-4476
  • Fax: 716-332-4479
Mailing address:
  • Phone: 716-332-4476
  • Fax: 716-332-4479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number183745
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number183745
License Number StateNY

VIII. Authorized Official

Name: MS. ANNE ELIZABETH CAMPAGNA
Title or Position: OFFICE MANAGER
Credential:
Phone: 716-332-4476