1083709943 NPI number — DR. KERRY KATHLEEN GROHMAN PH.D.

Table of content: DR. KERRY KATHLEEN GROHMAN PH.D. (NPI 1083709943)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083709943 NPI number — DR. KERRY KATHLEEN GROHMAN PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROHMAN
Provider First Name:
KERRY
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.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:
1083709943
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
469 WASHINGTON HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMHERST
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14226-4648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-833-3827
Provider Business Mailing Address Fax Number:
716-833-9710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3495 BAILEY AVE
Provider Second Line Business Practice Location Address:
VA-WNYHS, 116B
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14215-1129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-833-3827
Provider Business Practice Location Address Fax Number:
716-833-9710
Provider Enumeration Date:
10/04/2006

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: 103G00000X , with the licence number:  015340-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC1900X , with the licence number: 015340-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 02407041 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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