NPIMap

Organization Active NPI

Great Lakes Medical Imaging LLC

  • Diagnostic Radiology Physician
  • Williamsville, NY
National Provider Identifier
1861763005
Registry record updated Aug 21, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
Legal business name
GREAT LAKES MEDICAL IMAGING LLC
Practice address
111 N Maplemere Rd Ste 120
Williamsville, NY 14221-3178
Phone
(716) 836-4646
Fax
(716) 836-4696
NPI assigned
Jan 19, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 21, 2023

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

Authorized official

Name
Kenneth D Pearsen, MDNPI 1154387918
Title
MD
Phone
(716) 836-4646

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2085R0202X Primary

Addresses

Primary practice location

111 N Maplemere Rd Ste 120
Williamsville, NY 14221-3178

Mailing address

111 N Maplemere Rd Ste 120
Williamsville, NY 14221-3178
Phone (716) 836-4646

Other identifiers 1

IdentifierTypeStateIssuer
03428622MedicaidNY

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120316000017 NY Part B Supplier - Clinic/Group Practice 2163681859 Receives reassigned benefits from 57 practitioners
Practice locations: Buffalo, NY; Cheektowaga, NY; Olean, NY; Orchard Park, NY; Sanborn, NY; Williamsville, NY

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
33D2018926Great Lakes Medical Imaging LLC111 North Maplemere - Suite 120, Williamsville, NY 14221Certificate of waiverMar 26, 2027

National Provider Directory

National Provider Directory

Locations

500 University Ave
Ste 260
Sacramento, CA 95825
Phone (916) 929-6705

3620 Sheridan Dr
#300
Amherst, NY 14226
Phone (713) 931-4908

110 Crystal Run Rd
Ste 101
Middletown, NY 10941
Phone (845) 673-6446

500 Sterling Dr
#2
Orchard Park, NY 14127

3850 Saunders Settlement Rd
Ste 150
Sanborn, NY 14132

3850 Saunders Settlement Rd
#105
Sanborn, NY 14132

3850 Saunders Settlement Rd
#150
Sanborn, NY 14132

2733 Wehrle Dr
Ste 500
Williamsville, NY 14221
Phone (716) 580-3648

Practitioners & affiliated clinicians

Practitioners 60

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

View all 60

NPI Registry JSON

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

{
    "created_epoch": "1326931200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1692576000000",
    "number": "1861763005",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "111 N MAPLEMERE RD STE 120",
            "city": "WILLIAMSVILLE",
            "state": "NY",
            "postal_code": "142213178",
            "telephone_number": "716-836-4646",
            "fax_number": "716-836-4696"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 N MAPLEMERE RD STE 120",
            "city": "WILLIAMSVILLE",
            "state": "NY",
            "postal_code": "142213178",
            "telephone_number": "716-836-4646",
            "fax_number": "716-836-4696"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES MEDICAL IMAGING LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-01-19",
        "last_updated": "2023-08-21",
        "certification_date": "2023-08-21",
        "status": "A",
        "authorized_official_last_name": "PEARSEN",
        "authorized_official_first_name": "KENNETH",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "MD",
        "authorized_official_telephone_number": "716-836-4646",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Radiology, Diagnostic Radiology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "03428622",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Williamsville, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 21, 2023; 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.