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General NPI Number Information
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NPI Number | 1568618353
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Entity Type | Organization
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Legal Business Name | WESTERN NEW YORK MED-PSYCH PLLC
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Dates
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Enumeration Date | 08/12/2008
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Last Update Date | 04/21/2009
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Provider Practice Location Address
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Address Line | 1001 E 2ND ST
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City | COUDERSPORT
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State | PA
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Zip | 16915-8161
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Country | US
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Telephone | 800-324-8820
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Fax |
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Provider Business Mailing Address
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Address Line | 111 E 14TH ST
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City | ELMIRA HEIGHTS
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State | NY
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Zip | 14903-1303
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Country | US
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Telephone | 607-734-9539
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Fax | 607-734-6293
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Authorized Official
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Title or Position | OWNER
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Name | SAMPATH NEERUKONDA
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Credential | M.D.
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Telephone | 607-324-3580
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | MD052162L
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License Number State | PA
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