NPIMap

Organization Active NPI

Eastern Niagara Medical Group

  • Family Medicine Physician
  • Lockport, NY
National Provider Identifier
1346796398
Registry record updated Sep 1, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
3101000H Issued in NY
Legal business name
EASTERN NIAGARA MEDICAL GROUP
Practice address
53 Elizabeth Dr
Lockport, NY 14094-5226
Phone
(716) 514-5501
Fax
(716) 514-5549
NPI assigned
Aug 30, 2016
Last updated
Sep 1, 2016By the provider in NPPES
Organization subpart
Yes
Parent organization
EASTERN NIAGARA HOSPITAL, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 1, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Michael Francis Ickowski Sr., MBA, CPA
Title
Cfo
Phone
(716) 514-5501

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 3101000H NY Primary
Internal Medicine Physician 207R00000X 3101000H NY
Gastroenterology Physician 207RG0100X 3101000H NY

Addresses

Primary practice location

53 Elizabeth Dr
Lockport, NY 14094-5226

Mailing address

521 East Ave
Lockport, NY 14094-3201
Phone (716) 514-5501

Other identifiers 2

IdentifierTypeStateIssuer
3101000HOtherNYLICENSE NUMBER - OPERATING CERTIFICATE
00354389MedicaidNY

National Provider Directory

National Provider Directory
Part of
David a Pike

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1472515200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1472688000000",
    "number": "1346796398",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "521 EAST AVE",
            "city": "LOCKPORT",
            "state": "NY",
            "postal_code": "140943201",
            "telephone_number": "716-514-5501",
            "fax_number": "716-514-5549"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "53 ELIZABETH DR",
            "city": "LOCKPORT",
            "state": "NY",
            "postal_code": "140945226",
            "telephone_number": "716-514-5501",
            "fax_number": "716-514-5549"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EASTERN NIAGARA MEDICAL GROUP",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "EASTERN NIAGARA HOSPITAL, INC",
        "enumeration_date": "2016-08-30",
        "last_updated": "2016-09-01",
        "status": "A",
        "authorized_official_last_name": "ICKOWSKI",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "FRANCIS",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "716-514-5501",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Sr.",
        "authorized_official_credential": "MBA, CPA"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NY",
            "license": "3101000H",
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NY",
            "license": "3101000H",
            "primary": false
        },
        {
            "code": "207RG0100X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Gastroenterology",
            "state": "NY",
            "license": "3101000H",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSE NUMBER - OPERATING CERTIFICATE",
            "identifier": "3101000H",
            "state": "NY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00354389",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lockport, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 1, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.