Provider Demographics
NPI:1871379586
Name:ROSWELL PARK CANCER INSTITUTE
Entity type:Organization
Organization Name:ROSWELL PARK CANCER INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:716-845-5772
Mailing Address - Street 1:ELM AND CARLTON ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14263-0001
Mailing Address - Country:US
Mailing Address - Phone:716-845-5785
Mailing Address - Fax:
Practice Address - Street 1:203 PARK CLUB LANE
Practice Address - Street 2:SUITE Z-200
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-845-8936
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354518Medicaid