Provider Demographics
NPI:1104087915
Name:STALL SENIOR MEDICAL LLC
Entity type:Organization
Organization Name:STALL SENIOR MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:STALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-833-3237
Mailing Address - Street 1:4242 RIDGE LEA RD STE 26
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-5120
Mailing Address - Country:US
Mailing Address - Phone:716-833-3237
Mailing Address - Fax:888-976-5853
Practice Address - Street 1:4242 RIDGE LEA RD STE 26
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226
Practice Address - Country:US
Practice Address - Phone:716-833-3237
Practice Address - Fax:888-976-5853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163872207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty