MEDICARE: ANDREA L. DEROSAS 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	223237	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00025948403	OTHER	NY	UNIVERA
2	000526772003	OTHER	NY	BC/BS
3	0411408	OTHER	NY	IHA
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	151079BJ	OTHER	NY	PREFERRED CARE

General Provider Information

NPI Number	:	1588631485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA L. DEROSAS M.D.

Provider Business Mailing Address
First Line	:	400 FOREST AVE
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14213-1207
Country	:	US
Telephone Number	:	716-816-2515
Fax Number	:	716-816-2066

Provider Business Practice Location Address
First Line	:	400 FOREST AVE
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14213-1207
Country	:	US
Telephone Number	:	716-816-2515
Fax Number	:

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

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	07/08/2007

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