1871565861 NPI number — DR. KENNETH H DAVIDSON MD

Table of content: DR. KENNETH H DAVIDSON MD (NPI 1871565861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871565861 NPI number — DR. KENNETH H DAVIDSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIDSON
Provider First Name:
KENNETH
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1871565861
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1415 PORTLAND AVE
Provider Second Line Business Mailing Address:
SUITE 350
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14621-3038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-426-9278
Provider Business Mailing Address Fax Number:
585-338-2738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1415 PORTLAND AVE
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14621-3038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-426-9278
Provider Business Practice Location Address Fax Number:
585-338-2738
Provider Enumeration Date:
02/03/2006

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: 207RC0000X , with the licence number:  103663 , 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: 005002871 . This is a "BLUE SHIELD WESTERN NY" identifier . This identifiers is of the category "OTHER".
  • Identifier: P010103663 . This is a "BLUE CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 07341 . This is a "CHOICE CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10453 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9913 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: Y019296 . This is a "CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00450853 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: MD4426 . This is a "PREFERRED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 005002871 . This is a "COMMUNITY BLUE" identifier . This identifiers is of the category "OTHER".




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