MEDICARE: EDEN PRIMARY CARE

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207Q00000X	Family Medicine Physician
2	207QG0300X	Geriatric Medicine (Family Medicine) Physician
3	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	301295	OTHER	NY	NYS MEDICAL LICENSE

General Provider Information

NPI Number	:	1154071934
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDEN PRIMARY CARE

Provider Business Mailing Address
First Line	:	8274 N MAIN ST
Second Line	:
City	:	EDEN
State	:	NY
Zip	:	14057-1104
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8274 N MAIN ST
Second Line	:
City	:	EDEN
State	:	NY
Zip	:	14057-1104
Country	:	US
Telephone Number	:	716-725-8114
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRIGID O'GORMAN
Credential	:	MD
Telephone Number	:	716-575-7282

Provider Enumeration Date	:	03/25/2022
Last Update Date	:	08/06/2022

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Directions to “EDEN PRIMARY CARE ” Practice Location

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