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General NPI Number Information
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NPI Number | 1063611192
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Entity Type | Organization
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Legal Business Name | KENWOOD PEDIATRICS
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Dates
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Enumeration Date | 07/18/2007
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Last Update Date | 04/20/2020
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Provider Practice Location Address
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Address Line | 2121 MAIN ST, STE 119
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City | BUFFALO
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State | NY
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Zip | 14214
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Country | US
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Telephone | 716-838-6655
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Fax |
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Provider Business Mailing Address
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Address Line | 381 KENMORE AVE
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City | BUFFALO
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State | NY
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Zip | 14223-2861
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Country | US
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Telephone | 716-838-1560
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Fax | 716-833-1221
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Authorized Official
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Title or Position | PHYSICIAN
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Name | MRS. GRACE DIMITROFF
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Credential | M.D.
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Telephone | 716-838-6655
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State | NY
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