1972772838 NPI number — DR. MARY ELIZABETH ROEHMHOLDT M.D.

Table of content: DR. MARY ELIZABETH ROEHMHOLDT M.D. (NPI 1972772838)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972772838 NPI number — DR. MARY ELIZABETH ROEHMHOLDT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROEHMHOLDT
Provider First Name:
MARY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
DR.
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:
1972772838
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 ESSJAY RD
Provider Second Line Business Mailing Address:
STE 105
Provider Business Mailing Address City Name:
WILLIAMSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14221-8208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-634-6357
Provider Business Mailing Address Fax Number:
716-634-3448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 ESSJAY RD
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
WILLIAMSVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14221-8208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-634-6357
Provider Business Practice Location Address Fax Number:
716-634-3448
Provider Enumeration Date:
02/25/2008

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: 2084N0400X , with the licence number:  128036-1 , 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: CPN-N-128036-1 . This is a "NYS COMPENSATION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00481021 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 130003589 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00020058901 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 005077825 . This is a "BLUE CROSS /BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 389594 . This is a "WELLCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 05-02672 . This is a "IHA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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