Provider Demographics
NPI:1285682500
Name:WESTERN NEW YORK RADIOLOGY ASSOCIATES LLC
Entity type:Organization
Organization Name:WESTERN NEW YORK RADIOLOGY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:D
Authorized Official - Last Name:PEARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-859-2954
Mailing Address - Street 1:111 N MAPLEMERE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-3178
Mailing Address - Country:US
Mailing Address - Phone:716-836-4646
Mailing Address - Fax:716-836-4696
Practice Address - Street 1:100 HIGH ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1126
Practice Address - Country:US
Practice Address - Phone:716-859-2954
Practice Address - Fax:716-859-2962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02383255Medicaid
DA0528OtherRR MEDICARE
NYAA1553Medicare PIN