# EASTERN NIAGARA MEDICAL GROUP

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** EASTERN NIAGARA HOSPITAL, INC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1346796398
- **Legal business name:** EASTERN NIAGARA HOSPITAL, INC
- **Authorized official:** MR. MICHAEL FRANCIS ICKOWSKI SR. MBA, CPA (CFO)
- **Authorized official phone:** (716) 514-5501

## Contact information

- **Practice address:** 53 ELIZABETH DR, LOCKPORT, NY 14094-5226
- **Practice address phone:** (716) 514-5501
- **Practice address fax:** (716) 514-5549
- **Mailing address:** 521 EAST AVE, LOCKPORT, NY 14094-3201
- **Mailing address phone:** (716) 514-5501
- **Mailing address fax:** (716) 514-5549

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 3101000H | NY | Yes |
| 207R00000X | Internal Medicine Physician | 3101000H | NY | — |
| 207RG0100X | Gastroenterology Physician | 3101000H | NY | — |

## Other

- **Enumeration date:** 08/30/2016
- **Last updated:** 09/01/2016