Basic Information
| Provider Information | |||||||||
| NPI: | 1689708885 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KALEIDA HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 726 EXCHANGE ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142101484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168787000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 818 ELLICOTT ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163232000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 11/10/2017 | ||||||||
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| AuthorizedOfficialLastName: | LOSI | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7168598383 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KALEIDA HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 00360614 | 05 | NY | MEDICAID |