Healthcare Provider Details

I. General information

NPI: 1326330440
Provider Name (Legal Business Name): MICHAEL ROBERT TISO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2011
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N MAPLEMERE RD STE 100
WILLIAMSVILLE NY
14221-3182
US

IV. Provider business mailing address

4225 GENESEE ST STE 400
CHEEKTOWAGA NY
14225-1994
US

V. Phone/Fax

Practice location:
  • Phone: 716-204-3200
  • Fax: 716-204-4337
Mailing address:
  • Phone: 716-204-3200
  • Fax: 716-204-4337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number35.122274
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number35.122274
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number277182
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.122274
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: