MEDICARE: DR. KEVIN N. O'GORMAN M.D.

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	207R00000X	Internal Medicine Physician	140567-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00010352901	OTHER	NY	UNIVERA HEALTHCARE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0401559	OTHER	NY	INDEPENDENT HEALTH
4	000508426001	OTHER	NY	BC/BS OF WNY

General Provider Information

NPI Number	:	1083677231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN N. O'GORMAN M.D.

Provider Business Mailing Address
First Line	:	8600 DEPOT ST
Second Line	:
City	:	EDEN
State	:	NY
Zip	:	14057-1343
Country	:	US
Telephone Number	:	716-992-4999
Fax Number	:	716-992-9132

Provider Business Practice Location Address
First Line	:	8600 DEPOT ST
Second Line	:
City	:	EDEN
State	:	NY
Zip	:	14057-1343
Country	:	US
Telephone Number	:	716-992-4999
Fax Number	:	716-992-9132

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	07/08/2007

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