MEDICARE: DR. HENRY FREDERICK GOLLER 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	2085R0202X	Diagnostic Radiology Physician	089555	NY

General Provider Information

NPI Number	:	1649597949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HENRY FREDERICK GOLLER M.D.

Provider Business Mailing Address
First Line	:	40 BROOKINS GREEN DR
Second Line	:
City	:	ORCHARD PARK
State	:	NY
Zip	:	14127-2558
Country	:	US
Telephone Number	:	716-662-3871
Fax Number	:

Provider Business Practice Location Address
First Line	:	40 BROOKINS GREEN DR
Second Line	:
City	:	ORCHARD PARK
State	:	NY
Zip	:	14127-2558
Country	:	US
Telephone Number	:	716-662-3871
Fax Number	:

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

Provider Enumeration Date	:	04/26/2010
Last Update Date	:	04/26/2010

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