Provider Demographics
NPI:1215115662
Name:WNY BREAST MED AND SURG CARE,PC
Entity type:Organization
Organization Name:WNY BREAST MED AND SURG CARE,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-867-9177
Mailing Address - Street 1:55 SOUTHWICK DR
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1650
Mailing Address - Country:US
Mailing Address - Phone:716-897-9177
Mailing Address - Fax:
Practice Address - Street 1:55 SOUTHWICK DR
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1650
Practice Address - Country:US
Practice Address - Phone:716-897-9177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164393-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11321AMedicare PIN