1205813680 NPI number — KIMBERLY B PRISE M.D.

Table of content: KIMBERLY B PRISE M.D. (NPI 1205813680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205813680 NPI number — KIMBERLY B PRISE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRISE
Provider First Name:
KIMBERLY
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205813680
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4711 TRANSIT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14043-4888
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-668-5331
Provider Business Mailing Address Fax Number:
716-668-5370

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4711 TRANSIT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14043-4888
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-668-5331
Provider Business Practice Location Address Fax Number:
716-668-5370
Provider Enumeration Date:
12/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  209492 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00020521904 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 040426001948 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1210687 . This is a "IHA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 146561DL . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00020521904 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000525567004 . This is a "BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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