Healthcare Provider Details

I. General information

NPI: 1457757486
Provider Name (Legal Business Name): WAVERLY MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 BROAD ST
WAVERLY NY
14892-1441
US

IV. Provider business mailing address

348 BROAD ST
WAVERLY NY
14892-1441
US

V. Phone/Fax

Practice location:
  • Phone: 607-821-2444
  • Fax: 607-948-1030
Mailing address:
  • Phone: 607-821-2444
  • Fax: 607-948-1030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number276514
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number275859
License Number StateNY

VIII. Authorized Official

Name: DR. VICTOR OMAMODE IDAHOSA
Title or Position: OWNER
Credential: M.D.
Phone: 607-821-2444