=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790299832
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL ECP OF WESTERN NEW YORK P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2017
-----------------------------------------------------
Last Update Date | 06/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4330 MAPLE RD STE 102
-----------------------------------------------------
City | AMHERST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-245-3682
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2697 LAKEVILLE RD
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14414-9767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-245-3682
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL EDWARD MERHIGE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 585-245-3682
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 177166-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------