Provider Demographics
NPI:1770517765
Name:BUFFALO SPINE & SPORTS MEDICINE PC
Entity type:Organization
Organization Name:BUFFALO SPINE & SPORTS MEDICINE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:
Authorized Official - Last Name:ZILLIOUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-650-3115
Mailing Address - Street 1:100 COLLEGE PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221
Mailing Address - Country:US
Mailing Address - Phone:716-626-0093
Mailing Address - Fax:716-626-9193
Practice Address - Street 1:100 COLLEGE PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-626-0093
Practice Address - Fax:716-626-9193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1622591208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02396821Medicaid
NY02396821Medicaid