Provider Demographics
NPI:1174743173
Name:NORTHERN CHAUTAUQUA RADIOLOGY LLC
Entity type:Organization
Organization Name:NORTHERN CHAUTAUQUA RADIOLOGY LLC
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 110
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063-0110
Mailing Address - Country:US
Mailing Address - Phone:716-363-6342
Mailing Address - Fax:716-363-6345
Practice Address - Street 1:189 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NY
Practice Address - Zip Code:14787-1104
Practice Address - Country:US
Practice Address - Phone:716-363-9342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
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
000511785004OtherBLUE CROSS
00026704301OtherUNIVERA
NY01246304Medicaid
NY01246304Medicaid