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GREAT LAKES MEDICAL IMAGING LLC
NPI 1861763005
Radiology - Diagnostic Radiology in Williamsville, NY

Active since January 19, 2012CLIA 33D2018926 · Waiver
111 N MAPLEMERE RD STE 120, WILLIAMSVILLE, NY 14221(716) 836-4646(716) 836-4696 Get Directions Write a Review

NPPES record last updated: August 21, 2023. Verified against the NPPES registry weekly; last sync: November 01, 2026.

Record update history: Aug 21, 2023, Dec 17, 2020, Sep 25, 2018 (3 updates tracked since 2018).

About Great Lakes Medical Imaging Llc NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

GREAT LAKES MEDICAL IMAGING LLC (NPI 1861763005) is a healthcare organization registered as a diagnostic radiology in Williamsville, New York and active in the NPI registry since January 2012. The organization holds a CLIA Waiver certificate valid through March 26, 2027 and lists Kenneth D Pearsen, Md, as its authorized official.

NPPES Registry Identity

NPI1861763005
Entity TypeOrganization
Primary Taxonomy2085R0202X
Legal Business NameGREAT LAKES MEDICAL IMAGING LLC
Location Address111 N MAPLEMERE RD STE 120Williamsville, NY 14221-3178
Mailing Address111 N Maplemere Rd Ste 120Williamsville, NY 14221-3178 · (716) 836-4646 · Fax (716) 836-4696
Phone(716) 836-4646
Fax(716) 836-4696
Organization SubpartNo
Authorized OfficialKenneth D PearsenMd · (716) 836-4646
Enumeration DateJanuary 19, 2012
Last NPPES UpdateAugust 21, 20233 updates tracked since enumeration
NPPES CertifiedAugust 21, 2023
✔ NPI 1861763005 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyRadiology · Diagnostic RadiologyAllopathic & Osteopathic Physicians
Taxonomy Code2085R0202X
Definition
A radiologist who utilizes x-ray, radionuclides, ultrasound and electromagnetic radiation to diagnose and treat disease.
111 N MAPLEMERE RD STE 120, Williamsville, NY 14221
Open in Google Maps ↗

Other Identifiers 1

Medicaid03428622NY

Group Practice 1

Group TaxonomyThis provdier is a business group of one or more individual practitioners, all of who practice with the same area of specialization.193400000X SINGLE SPECIALTY GROUP

Medicare Participation & PECOS CMS

Medicare enrollment, revalidation and the clinicians who bill Medicare through this organization, from CMS.

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

Great Lakes Medical Imaging Llc is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).

Medicare Revalidation Due Date

Revalidation due by December 31, 2026

Medicare-enrolled providers and suppliers confirm their enrollment information with CMS on a set cycle, every 5 years for most and every 3 years for medical equipment suppliers. CMS sets the due date for each enrollment.

StateEnrollment IDDue date
StateNew YorkEnrollment IDO20120316000017Non-DME Part B · Clinic/Group PracticeDue dateDecember 31, 2026
Source: CMS Revalidation Due Date List, October 2026 release.

Clinicians Billing Medicare Through This Organization

45

Medicare enrollment records show 45 clinicians reassign Medicare billing to Great Lakes Medical Imaging LLC, which bills Medicare for the services they deliver. Of these, 28 practice at this address and 34 within 10 miles. Listed here are the 20 practicing nearest to this location.

Clinicians by Medicare Specialty 3

Diagnostic Radiology41
Nurse Practitioner3
Nuclear Medicine1

Nearest to this location (20)

See all 45
Phillip Baum, MD
Diagnostic Radiology
NPI 1023016060
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Thomas Bevilacqua, M.D.
Diagnostic Radiology
NPI 1093094005
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Jacob Chenez, DO
Diagnostic Radiology
NPI 1013479039
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Harris Chengazi, M.D.
Diagnostic Radiology
NPI 1861878837
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Omar Chohan, D.O.
Diagnostic Radiology
NPI 1154764918
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
David Cipolla, M.D.
Diagnostic Radiology
NPI 1740422708
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Adam Cole, M.D.
Diagnostic Radiology
NPI 1427336957
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Mark Diiulio, MD
Diagnostic Radiology
NPI 1063875763
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Douglas Drumsta, M.D.
Diagnostic Radiology
NPI 1124345566
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Joshua Dudziak, NP
Nurse Practitioner
NPI 1174333017
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Andrew Dunn, MD
Diagnostic Radiology
NPI 1346367935
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
William Hampton, MD
Diagnostic Radiology
NPI 1740247600
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Joseph Lang, M.D
Diagnostic Radiology
NPI 1225422504
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Thomas Lostracco, MD
Diagnostic Radiology
NPI 1558680611
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Benjamin Martin, MD
Diagnostic Radiology
NPI 1942731039
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
John Mcgrath, M.D.
Diagnostic Radiology
NPI 1134357429
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Christopher Nicholas, MD
Diagnostic Radiology
NPI 1457863904
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Merrie Oei, M.D.
Diagnostic Radiology
NPI 1801247713
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Roseanne Oliverio, MD
Diagnostic Radiology
NPI 1073516985
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
Kenneth Pearsen, MD
Diagnostic Radiology
NPI 1154387918
111 N MAPLEMERE RD STE 120
Williamsville, NY 14221
(716) 836-4646
✔ PECOS✔ Accepts MedicareSame address
See all 45 clinicians

Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 33D2018926

Great Lakes Medical Imaging LLC · Williamsville, NY
Active · expires Mar 26, 2027
CLIA Number33D2018926
Laboratory TypeImaging Center
Certificate Effective DateJanuary 19, 2011
Certificate Expiration DateMarch 26, 2027
Laboratory DirectorDr. James J. Rinaldi
Laboratory Phone(716) 836-4646
Laboratory LocationGreat Lakes Medical Imaging LLC111 North Maplemere - Suite 120, Williamsville, NY 14221
CLIA data matches this NPI record on: Name Phone
This certificate is issued to a laboratory to perform only waived tests.

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Great Lakes Medical Imaging LLC's NPI number?

The NPI number for Great Lakes Medical Imaging LLC is 1861763005. It was assigned to this organization in the NPPES registry on January 19, 2012.

Where is Great Lakes Medical Imaging LLC located?

Great Lakes Medical Imaging LLC is located at 111 N Maplemere Rd Ste 120, Williamsville, NY 14221. The listed phone number is (716) 836-4646.

What is Great Lakes Medical Imaging LLC's specialty?

The primary specialty registered for this NPI is Radiology, specializing in Diagnostic Radiology, with taxonomy code 2085R0202X.

Is Great Lakes Medical Imaging LLC enrolled in Medicare?

Yes. Great Lakes Medical Imaging LLC is registered in the Medicare PECOS enrollment system.

When is Great Lakes Medical Imaging LLC's Medicare revalidation due?

According to the CMS Revalidation Due Date List (October 2026 release), the Medicare Non-DME Part B enrollment for this organization (New York, Clinic/Group Practice) is due for revalidation by December 31, 2026. Medicare providers and suppliers revalidate their enrollment every 5 years, and medical equipment suppliers every 3 years. Confirm current requirements with your Medicare Administrative Contractor.

How many clinicians bill Medicare through Great Lakes Medical Imaging LLC?

According to the CMS Revalidation Reassignment List (October 2026 release), 45 clinicians in 3 Medicare specialties reassign their Medicare billing to Great Lakes Medical Imaging LLC. A reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for the clinician's services. The largest specialties are Diagnostic Radiology (41), Nurse Practitioner (3) and Nuclear Medicine (1). Of these, 28 practice at this address and 34 within 10 miles. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

Does Great Lakes Medical Imaging LLC hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 33D2018926) is associated with this NPI, valid through March 26, 2027. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Great Lakes Medical Imaging LLC was last updated on August 21, 2023. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 3 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.