Waverly Medical Associates LLC

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

276514 Issued in NY

Legal business name

WAVERLY MEDICAL ASSOCIATES LLC

Practice address

348 Broad St
Waverly, NY 14892-1441

Phone

(607) 821-2444

Fax

(607) 948-1030

NPI assigned

Nov 19, 2014

Organization subpart

No

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

Authorized official

Name

Dr. Victor Omamode Idahosa, M.D.NPI 1528226677

Title

Owner

Phone

(607) 821-2444

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in NY

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Victor Omamode Idahosa, MD

  • Addiction Medicine (Internal Medicine) Physician
  • Waverly, NY
  • NPI 1528226677

  NY

  Medicare reassignment Care Compare group NPD Authorized official
• Ejiro Vivian Agboro-Idahosa, M.D

  • Child & Adolescent Psychiatry Physician
  • Elmira, NY
  • NPI 1104089390

  NY, Psychiatry

  Medicare reassignment Care Compare group NPD

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

{
    "created_epoch": "1416355200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1474588800000",
    "number": "1457757486",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "348 BROAD ST",
            "city": "WAVERLY",
            "state": "NY",
            "postal_code": "148921441",
            "telephone_number": "607-821-2444",
            "fax_number": "607-948-1030"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "348 BROAD ST",
            "city": "WAVERLY",
            "state": "NY",
            "postal_code": "148921441",
            "telephone_number": "607-821-2444",
            "fax_number": "607-948-1030"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAVERLY MEDICAL ASSOCIATES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-11-19",
        "last_updated": "2016-09-23",
        "status": "A",
        "authorized_official_last_name": "IDAHOSA",
        "authorized_official_first_name": "VICTOR",
        "authorized_official_middle_name": "OMAMODE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "607-821-2444",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "NY",
            "license": "276514",
            "primary": true
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NY",
            "license": "275859",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kristen Vandyke
• Jennifer Wagner, NP
• Molly Sue Wallace-Welch, RN, BSN
• Patricia Louise Ward, RPT
• Waverly Central School District
• We Play Speech & Physical Therapy Services PLLC
• Laura Lynne Willliams

• Internal Medicine Physician in Waverly, NY
• Providers in Waverly, NY by specialty
• Internal Medicine Physician in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 23, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.