Basic Information
| Provider Information | |||||||||
| NPI: | 1114976214 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | ALBARELLI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 E ADAMS ST | ||||||||
| Address2: | CENTER FOR CHILDREN'S CANCER AND BLOOD DISORDERS | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132102306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645294 | ||||||||
| FaxNumber: | 3154647238 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 E ADAMS ST | ||||||||
| Address2: | CENTER FOR CHILDREN'S CANCER AND BLOOD DISORDERS | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132102306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645294 | ||||||||
| FaxNumber: | 3154647238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 09/18/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 1904401 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0207X | 1904401 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 01603401 | 05 | NY | MEDICAID |