=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760557508
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESTERN NEW YORK RETINA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 04/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5225 SHERIDAN DR GEORGETOWN SQUARE PLAZA
-----------------------------------------------------
City | WILLIAMSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14221-3573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-204-5440
-----------------------------------------------------
Fax | 716-204-5442
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 908 NIAGARA FALLS BLVD STE 208
-----------------------------------------------------
City | N TONAWANDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14120-2019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-692-2160
-----------------------------------------------------
Fax | 716-213-0935
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSEPH ANTHONY MURPHY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 716-204-5440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 217838
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------