Basic Information
Provider Information | |||||||||
NPI: | 1881652238 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KENYON | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | ANTHONY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1001 MAIN ST FL 5 | ||||||||
Address2: |   | ||||||||
City: | BUFFALO | ||||||||
State: | NY | ||||||||
PostalCode: | 142031009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7163230220 | ||||||||
FaxNumber: | 7163230293 | ||||||||
Practice Location | |||||||||
Address1: | 818 ELLICOTT ST | ||||||||
Address2: |   | ||||||||
City: | BUFFALO | ||||||||
State: | NY | ||||||||
PostalCode: | 142031021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7163230220 | ||||||||
FaxNumber: | 7163230293 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2006 | ||||||||
LastUpdateDate: | 01/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 228634 | NY | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080P0204X | 228634 | NY | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
ID | Type | State | Issuer | Description | 1292497 | 01 |   | IHA | OTHER | 040426003098 | 01 |   | FIDELIS | OTHER | 100831371001 | 05 | PA |   | MEDICAID | 00026380601 | 01 |   | UNIVERA | OTHER | 000527294001 | 01 |   | BC/BS | OTHER | 02409052 | 05 | NY |   | MEDICAID |