1457547184 NPI number — KENNETH H. DAVIDSON, MD, PC

Table of content: (NPI 1457547184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457547184 NPI number — KENNETH H. DAVIDSON, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNETH H. DAVIDSON, MD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457547184
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1415 PORTLAND AVE
Provider Second Line Business Mailing Address:
SUITE 350
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14621-3038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-426-9278
Provider Business Mailing Address Fax Number:
585-338-2738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1415 PORTLAND AVE
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14621-3038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-426-9278
Provider Business Practice Location Address Fax Number:
585-338-2738
Provider Enumeration Date:
09/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIDSON
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
585-426-9278

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  103663 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Y019296 . This is a "CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00450853 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10453 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4273339 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9913 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: PO10103663 . This is a "BLUE CHOICE - EXCELLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 005002871 . This is a "BLUE SHIELD WESTERN NY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 005002871 . This is a "COMMUNITY BLUE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 07341 . This is a "CHOICE CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: MD4426 . This is a "PREFERRED CARE" identifier . This identifiers is of the category "OTHER".




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