Healthcare Provider Details

I. General information

NPI: 1568618353
Provider Name (Legal Business Name): WESTERN NEW YORK MED-PSYCH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E 2ND ST
COUDERSPORT PA
16915-8161
US

IV. Provider business mailing address

111 E 14TH ST
ELMIRA HEIGHTS NY
14903-1303
US

V. Phone/Fax

Practice location:
  • Phone: 800-324-8820
  • Fax:
Mailing address:
  • Phone: 607-734-9539
  • Fax: 607-734-6293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD052162L
License Number StatePA

VIII. Authorized Official

Name: SAMPATH NEERUKONDA
Title or Position: OWNER
Credential: M.D.
Phone: 607-324-3580