MEDICARE: CHURCHVILLE-CHILI FAMILY MEDICINE, LLC

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	261Q00000X	Clinic/Center	174814	NY
2	207Q00000X	Family Medicine Physician	174814	NY

General Provider Information

NPI Number	:	1326231291
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHURCHVILLE-CHILI FAMILY MEDICINE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 505
Second Line	:
City	:	N. CHILI
State	:	NY
Zip	:	14514
Country	:	US
Telephone Number	:	585-594-5995
Fax Number	:	585-594-5425

Provider Business Practice Location Address
First Line	:	4201 BUFFALO RD
Second Line	:	BOX 505
City	:	NORTH CHILI
State	:	NY
Zip	:	14514-1256
Country	:	US
Telephone Number	:	585-594-5995
Fax Number	:	585-594-5425

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. HENRY MIKOLAJ PASZKO
Credential	:	MD
Telephone Number	:	585-594-5994

Provider Enumeration Date	:	08/23/2007
Last Update Date	:	11/04/2014

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