Provider Demographics
NPI:1063400539
Name:EASTERN NIAGARA HOSPITAL, INC
Entity type:Organization
Organization Name:EASTERN NIAGARA HOSPITAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:ICKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CPA
Authorized Official - Phone:716-514-5501
Mailing Address - Street 1:521 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-3201
Mailing Address - Country:US
Mailing Address - Phone:716-514-5501
Mailing Address - Fax:716-514-5549
Practice Address - Street 1:521 EAST AVE
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-3201
Practice Address - Country:US
Practice Address - Phone:716-514-5501
Practice Address - Fax:716-514-5549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QE0700X
NY3101000H282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00011412701OtherUNIVERA BILLING #
NY000000031000OtherBCBS BILLING #
NY00354389Medicaid
NY000000030000OtherBCBS BILLING #
NY13OtherIHA BILLING #
NY89OtherIHA BILLING #
NY000000031000OtherBCBS BILLING #
NY330163Medicare Oscar/Certification