1003873365 NPI number — MRS. CARRIE DENISE CLINE III MA CCCA

Table of content: ALEXIS SHAE MATTSON (NPI 1750182200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003873365 NPI number — MRS. CARRIE DENISE CLINE III MA CCCA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLINE
Provider First Name:
CARRIE
Provider Middle Name:
DENISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
III
Provider Credential Text:
MA CCCA
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:
1003873365
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
352 HUNTINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUFFALO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14214-1542
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
416-874-4500
Provider Business Mailing Address Fax Number:
716-874-8145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2128 ELMWOOD AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14207-1910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
416-874-4500
Provider Business Practice Location Address Fax Number:
716-874-8145
Provider Enumeration Date:
04/28/2006

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: 231H00000X , with the licence number:  0018381 , 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: 01465154 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00026873201 . This is a "UNIVERA COMMERCIAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00026873201 . This is a "PLUSMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000576115007 . This is a "COMMUNITY BLUE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000576115007 . This is a "CB ADVANTAGE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000576115007 . This is a "CB LABOR HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000576115007 . This is a "COMMUNITY CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000576115007 . This is a "BCBS WNY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00026873201 . This is a "UNIVERA MEDICARE PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00026873201 . This is a "CHILDHEALTH PLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000576115007 . This is a "CHILD HEALTH PLUS FAMILY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00026873201 . This is a "ASO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000576115007 . This is a "HMO 100" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00026873201 . This is a "UNIVERA HEALTHCARE TRADI" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00187911 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000576115007 . This is a "HEALTHY NY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000576115007 . This is a "SENIOR BLUE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000576115007 . This is a "TRADITIONAL" identifier . This identifiers is of the category "OTHER".




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