Healthcare Provider Details

I. General information

NPI: 1407813058
Provider Name (Legal Business Name): FORESTREAM PEDIATRICS, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4711 TRANSIT RD SUITE1
DEPEW NY
14043-4888
US

IV. Provider business mailing address

4711 TRANSIT RD SUITE1
DEPEW NY
14043-4888
US

V. Phone/Fax

Practice location:
  • Phone: 716-668-5331
  • Fax: 716-668-5370
Mailing address:
  • Phone: 716-668-5331
  • Fax: 716-668-5370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY PRISE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 716-668-5331