1477803161 NPI number — MRS. KRISTINA LORRAINE BLYTHE DPT

Table of content: EDWARD M BURDOCK DC CCSP (NPI 1417086760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477803161 NPI number — MRS. KRISTINA LORRAINE BLYTHE DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLYTHE
Provider First Name:
KRISTINA
Provider Middle Name:
LORRAINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JAROSZ
Provider Other First Name:
KRISTINA
Provider Other Middle Name:
LORRAINE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477803161
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
560 DELAWARE AVE
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
BUFFALO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14202-1212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-682-6201
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4650 SOUTHWESTERN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMBURG
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-646-7424
Provider Business Practice Location Address Fax Number:
716-312-3001
Provider Enumeration Date:
09/11/2012

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: 225100000X , with the licence number:  031612-1 , 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)





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