Provider Demographics
NPI:1861611956
Name:CHAUTAUQUA RADIOLOGY, PC
Entity type:Organization
Organization Name:CHAUTAUQUA RADIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:A
Authorized Official - Last Name:MUNTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-363-6342
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063-0069
Mailing Address - Country:US
Mailing Address - Phone:716-672-8040
Mailing Address - Fax:716-672-8060
Practice Address - Street 1:529 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:NY
Practice Address - Zip Code:14048-2514
Practice Address - Country:US
Practice Address - Phone:716-672-8040
Practice Address - Fax:716-672-8060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1857982085D0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic NeuroimagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000511785003OtherBLUE CROSS
NY01943026Medicaid
5609140OtherINDEPENDENT HEALTH
00026704302OtherUNIVERA
NY01246304Medicaid
CM1926OtherRR MEDICARE
00026704302OtherUNIVERA