Basic Information
Provider Information | |||||||||
NPI: | 1245365196 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KALEIDA HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JOHN R. OISHEI CHILDREN'S HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 726 EXCHANGE ST STE 300 | ||||||||
Address2: |   | ||||||||
City: | BUFFALO | ||||||||
State: | NY | ||||||||
PostalCode: | 142101467 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7168598556 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 818 ELLICOTT ST | ||||||||
Address2: |   | ||||||||
City: | BUFFALO | ||||||||
State: | NY | ||||||||
PostalCode: | 142031021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7163232000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2007 | ||||||||
LastUpdateDate: | 10/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAMES | ||||||||
AuthorizedOfficialFirstName: | URIAS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AR MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7168598556 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | KALEIDA HEALTH | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   | NY | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 00360614 | 05 | NY |   | MEDICAID |