1912936121 NPI number — JENNIFER ROLLER M.D.

Table of content: JENNIFER ROLLER M.D. (NPI 1912936121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912936121 NPI number — JENNIFER ROLLER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROLLER
Provider First Name:
JENNIFER
Provider Middle Name:
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:
1912936121
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2625 HARLEM RD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
CHEEKTOWAGA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14225-4031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-893-7337
Provider Business Mailing Address Fax Number:
716-893-7699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2625 HARLEM RD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
CHEEKTOWAGA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14225-4031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-893-7337
Provider Business Practice Location Address Fax Number:
716-893-7699
Provider Enumeration Date:
07/01/2006

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:  229568 , 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: 145776DL . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000527405001 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1211730 . This is a "INDEPENDENT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00026491301 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 050602000020 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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