Provider Demographics
NPI:1427017300
Name:WNY SKIN SURGERY AND DERMATOLOGY PC
Entity type:Organization
Organization Name:WNY SKIN SURGERY AND DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-631-1622
Mailing Address - Street 1:2805 WEHRLE DR
Mailing Address - Street 2:SUITE 10
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7382
Mailing Address - Country:US
Mailing Address - Phone:716-631-1622
Mailing Address - Fax:716-632-4116
Practice Address - Street 1:2805 WEHRLE DR
Practice Address - Street 2:SUITE 10
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7382
Practice Address - Country:US
Practice Address - Phone:716-631-1622
Practice Address - Fax:716-632-4116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2301181207ND0101X
NY230118-1261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ04409Medicare UPIN
NYPA0522Medicare ID - Type UnspecifiedMELISSA SPENCER, PA
NYH15712Medicare UPIN
NYBA0030Medicare ID - Type UnspecifiedMICHELLE L BENNETT, MD