Healthcare Provider Details

I. General information

NPI: 1316292014
Provider Name (Legal Business Name): ROSWELL PARK CANCER INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROSWELL PARK CANCER INSTITUTE ELM & CARLTON STREET
BUFFALO NY
14263-0001
US

IV. Provider business mailing address

275B EVANS ST APT # 6
WILLIAMSVILLE NY
14221-5666
US

V. Phone/Fax

Practice location:
  • Phone: 716-845-4101
  • Fax: 716-845-3423
Mailing address:
  • Phone: 507-319-1774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code284300000X
TaxonomySpecial Hospital
License Number
License Number StateNY

VIII. Authorized Official

Name: THANYANAN REUNGWETWATTANA
Title or Position: FELLOW
Credential: M.D.
Phone: 507-319-1774