Basic Information
| Provider Information | |||||||||
| NPI: | 1720036593 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROSWELL PARK CANCER INSTITUTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | ELM AND CARLTON ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168452300 | ||||||||
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| Practice Location | |||||||||
| Address1: | ELM AND CARLTON ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168452300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 06/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | CANDACE | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 7168452300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 02997079 | 05 | NY | MEDICAID |