Provider Demographics
NPI:1568456424
Name:GRISWOLD, KIM S (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:S
Last Name:GRISWOLD
Suffix:
Gender:F
Credentials:MD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:155 LAWN AVE
Mailing Address - Street 2:NORTHWEST BUFFALO COMMUNITY HEALTH CARE CENTER
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14207-1816
Mailing Address - Country:US
Mailing Address - Phone:716-875-2904
Mailing Address - Fax:716-875-6717
Practice Address - Street 1:155 LAWN AVE
Practice Address - Street 2:NORTHWEST BUFFALO COMMUNITY HEALTH CARE CENTER
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14207
Practice Address - Country:US
Practice Address - Phone:716-875-2904
Practice Address - Fax:716-875-6717
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2009871207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01762725Medicaid
NY14381FMedicare ID - Type Unspecified
G31676Medicare UPIN