Provider Demographics
NPI:1104069525
Name:JUNCEWICZ, EDMUND ANDREW (DO)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:ANDREW
Last Name:JUNCEWICZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 ELMWOOD AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-2646
Mailing Address - Country:US
Mailing Address - Phone:716-874-1098
Mailing Address - Fax:716-874-9616
Practice Address - Street 1:2950 ELMWOOD AVENUE (KENMORE MERCY HOSPITAL)
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1304
Practice Address - Country:US
Practice Address - Phone:716-447-6580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-15
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY269563-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03631454Medicaid