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General NPI Number Information
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NPI Number | 1356447270
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Entity Type | Organization
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Legal Business Name | SOUTHTOWNS INTERNAL MEDICINE PC
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Dates
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Enumeration Date | 09/16/2006
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Last Update Date | 09/11/2013
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Provider Practice Location Address
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Address Line | 3320 N BENZING RD
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City | ORCHARD PARK
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State | NY
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Zip | 14127-1538
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Country | US
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Telephone | 716-825-0300
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Fax | 716-825-0303
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Provider Business Mailing Address
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Address Line | 3320 NORTH BENZING ROAD
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City | ORCHARD PARK
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State | NY
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Zip | 14127-5138
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Country | US
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Telephone | 716-825-0300
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Fax | 716-825-0303
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Authorized Official
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Title or Position | DO
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Name | MR. GARY R NELSON
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Credential |
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Telephone | 716-825-0300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 177472
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License Number State | NY
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