1316292014 NPI number — ROSWELL PARK CANCER INSTITUTE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316292014 NPI number — ROSWELL PARK CANCER INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSWELL PARK CANCER INSTITUTE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1316292014
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
275B EVANS ST
Provider Second Line Business Mailing Address:
APT # 6
Provider Business Mailing Address City Name:
WILLIAMSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14221-5666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-319-1774
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ROSWELL PARK CANCER INSTITUTE
Provider Second Line Business Practice Location Address:
ELM & CARLTON STREET
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14263-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-845-4101
Provider Business Practice Location Address Fax Number:
716-845-3423
Provider Enumeration Date:
07/18/2012

Additional Information

Authorized Official

Authorized Official Last Name:
REUNGWETWATTANA
Authorized Official First Name:
THANYANAN
Authorized Official Middle Name:
Authorized Official Title or Position:
FELLOW
Authorized Official Telephone Number:
507-319-1774

Provider Taxonomy Codes

  • Taxonomy code: 284300000X , 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)





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