MEDICARE: KENMORE URGENT CARE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QU0200X	Urgent Care Clinic/Center	102346	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033545454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENMORE URGENT CARE PLLC

Provider Business Mailing Address
First Line	:	2949 ELMWOOD AVE
Second Line	:	SUITE 104
City	:	KENMORE
State	:	NY
Zip	:	14217-1356
Country	:	US
Telephone Number	:	716-876-7606
Fax Number	:	716-876-7608

Provider Business Practice Location Address
First Line	:	2949 ELMWOOD AVE
Second Line	:	SUITE 104
City	:	KENMORE
State	:	NY
Zip	:	14217-1356
Country	:	US
Telephone Number	:	716-876-7606
Fax Number	:	716-876-7608

Authorized Official
Title or Position	:	OWNERR
Name	:	DR. TARIK ELIBOL
Credential	:	M.D.
Telephone Number	:	716-876-7606

Provider Enumeration Date	:	09/17/2013
Last Update Date	:	09/18/2013

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