Basic Information
| Provider Information | |||||||||
| NPI: | 1316292014 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROSWELL PARK CANCER INSTITUTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275B EVANS ST | ||||||||
| Address2: | APT # 6 | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073191774 | ||||||||
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| Practice Location | |||||||||
| Address1: | ROSWELL PARK CANCER INSTITUTE | ||||||||
| Address2: | ELM & CARLTON STREET | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168454101 | ||||||||
| FaxNumber: | 7168453423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2012 | ||||||||
| LastUpdateDate: | 07/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | REUNGWETWATTANA | ||||||||
| AuthorizedOfficialFirstName: | THANYANAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | FELLOW | ||||||||
| AuthorizedOfficialTelephone: | 5073191774 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | NY | Y | Hospitals | Special Hospital |
No ID Information.