Provider Demographics
NPI:1902913098
Name:EASTERN NIAGARA MEDICAL GROUP PC
Entity Type:Organization
Organization Name:EASTERN NIAGARA MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HANY
Authorized Official - Middle Name:
Authorized Official - Last Name:FATTOUCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-798-3992
Mailing Address - Street 1:534 MAIN ST
Mailing Address - Street 2:SUITE 14
Mailing Address - City:MEDINA
Mailing Address - State:NY
Mailing Address - Zip Code:14103-1436
Mailing Address - Country:US
Mailing Address - Phone:585-798-3992
Mailing Address - Fax:585-798-3865
Practice Address - Street 1:521 EAST AVE
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-3201
Practice Address - Country:US
Practice Address - Phone:716-514-5648
Practice Address - Fax:716-514-5788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02051605Medicaid
NY02051605Medicaid