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Ontario Certificate of Status Non- Profit Corporation document sample
Document Sample
465 Status 465 App Number 1. HCP Number
2: Denied - Ineligible 17268-01-0001 17268
1: Approved 17268-01-0002 17268
1: Approved 17268-01-0003 17268
1: Approved 17268-01-0004 17268
1: Approved 17268-01-0005 17268
1: Approved 17268-01-0006 17268
1: Approved 17268-01-0007 17268
1: Approved 17268-01-0008 17268
1: Approved 17268-01-0009 17268
1: Approved 17268-01-0010 17268
1: Approved 17268-01-0011 17268
1: Approved 17268-01-0012 17268
1: Approved 17268-01-0013 17268
1: Approved 17268-01-0014 17268
1: Approved 17268-01-0015 17268
1: Approved 17268-01-0016 17268
1: Approved 17268-01-0017 17268
1: Approved 17268-01-0018 17268
1: Approved 17268-01-0019 17268
1: Approved 17268-01-0020 17268
1: Approved 17268-01-0021 17268
1: Approved 17268-01-0022 17268
1: Approved 17268-01-0023 17268
1: Approved 17268-01-0024 17268
1: Approved 17268-01-0025 17268
1: Approved 17268-01-0026 17268
1: Approved 17268-01-0027 17268
1: Approved 17268-01-0028 17268
1: Approved 17268-01-0029 17268
1: Approved 17268-01-0030 17268
1: Approved 17268-01-0031 17268
1: Approved 17268-01-0032 17268
1: Approved 17268-01-0033 17268
1: Approved 17268-01-0034 17268
1: Approved 17268-01-0035 17268
1: Approved 17268-01-0036 17268
1: Approved 17268-01-0037 17268
1: Approved 17268-01-0038 17268
1: Approved 17268-01-0039 17268
1: Approved 17268-01-0040 17268
1: Approved 17268-01-0041 17268
2. Consortium Name
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
3. HCP Name 4. HCP FCC Reg Num
Western New York Rural Area Health Education Center 0017512393
Brooks Memorial Hospital 0017512393
Catholic Health System 0017512393
Clifton Springs Hospital & Health Clinic 0017512393
Ira Davenport Memorial Hospital, Inc. 0017512393
Erie County Medical Center Corporation (ECMC) 0017512393
Finger Lakes Migrant Health Care, Inc. (Sodus Clinic) 0017512393
Finger Lakes Migrant Health Care, Inc. (Geneva Clinic) 0017512393
Finger Lakes Migrant Health Care, Inc. (Port Byron Clinic) 0017512393
Geneva General Hospital 0017512393
Jones Memorial Hospital 0017512393
Kaleida Health 0017512393
Lakeside Health System 0017512393
Medina Memorial Health Care System 0017512393
Mount St. Mary's Hospital and Health Center 0017512393
Niagara Falls Memorial Medical Center 0017512393
Nicholas H. Noyes Memorial Hospital 0017512393
Oak Orchard Community Health Center, Inc. (West Ave - Brockport Clinic) 0017512393
Oak Orchard Community Health Center, Inc. (Lyndonville Clinic) 0017512393
Oak Orchard Community Health Center, Inc. (West Ave - Ablion Clinic) 0017512393
Oak Orchard Community Health Center, Inc. (Albion Clinic) 0017512393
Olean General Hospital 0017512393
Planned Parenthood of Western New York (Lockport Site) 0017512393
Planned Parenthood of Western New York (Niagara Falls Site) 0017512393
Rochester General (Via Health) 0017512393
Schuyler Hospital 0017512393
St. James Mercy Health System 0017512393
St. Joseph's Hospital 0017512393
The Resource Center 0017512393
Thompson Health 0017512393
Tri-County Memorial Hospital 0017512393
Academic Medical Services 0017512393
UB Family Medicine, Inc. 0017512393
UB School of Medicine & Biomedical Sciences 0017512393
University at Buffalo - Neurosurgery 0017512393
United Memorial Medical Center 0017512393
University Orthopaedic Services, Inc. 0017512393
WCA Hospital 0017512393
Westfield Memorial Hospital 0017512393
Wyoming County Community Health System 0017512393
Lakeshore Health Care Center 0017512393
5a. Contact, First Name 5b. Contact, Middle Initial 5c. Contact, Last Name
Kenneth L Oakley, PhD, FACHE
Richard Ketchum
Joseph D McDonald
David Markant
James B Watson
Michael A Young
Mary Ann Zelazny
Mary Ann Zelazny
Mary Ann Zelazny
James J Dooley
Robert J Bruckner
James R Kaskie
John Schrenker
James E Sinner
Judith Maness
Anthony F Zito
James Wissler
Dave W Fisher
Dave W Fisher
Dave W Fisher
Dave W Fisher
Timothy J Finan
Karen J Nelson
Karen J Nelson
David B Kamowski
V. Richard Stelzer, Jr., FACHE
Mary E LaRowe
Sister Marie Castagnaro, SSJ
Paul Cesana
Deborah K Weymouth
Louis Frascella
Alan R Saltzman, MD, MBA
Kathleen Duttge
Judith K Miller
Mary Ann Kedron
Mark C Schoell
Michael Rogers
Betsy T Wright, FACHE
C. Angela Bontempo, FACHE
Ronald J Krawiec
Louis Frascella
6. Address Line 1 7. Address Line 2 8. County 9. City
20 Duncan Street PO BOX 152 Wyoming Warsaw
529 Central Ave Chautauqua Dunkirk
Seton Professional Bldg. 2121 Main Street; Suite 300 Erie Buffalo
2 Coulter Road Ontario Clifton Springs
7571 State Route 54 Steuben Bath
462 Grider Street Erie Buffalo
6692 Middle Road Suite 2100 Wayne Sodus
601B Washington Street Ontario Geneva
60 Main Street Cayuga Port Byron
196 North Street Ontario Geneva
191 North Main Street PO BOX 72 Allegany Wellsville
100 High Street Erie Buffalo
156 West Ave Monroe Brockport
200 Ohio Street Orleans Medina
5300 Military Road Niagara Lewiston
621 Tenth Street Niagara Niagara Falls
111 Clara Barton Street Livingston Dansville
300 West Ave Monroe Brockport
77 South Main Street Orleans Lyndonville
301 West Ave Orleans Albion
245 South Main Street Orleans Albion
515 Main Street Cattaraugus Olean
38 Heritage Court PO BOX 498 Niagara Lockport
732 Portage Road Haeberle Plaza Niagara Niagara Falls
333 Humboldt Street Monroe Rochester
220 Steuben Street Schuyler Montour Falls
411 Canisteo Street Steuben Hornell
555 East Market Street Chemung Elmira
800 East Second Street Chautauqua Jamestown
350 Parrish Street Ontario Canandaigua
100 Memorial Drive Cattaraugus Gowanda
462 Grider Street Erie Buffalo
462 Grider Street CC-162 Erie Buffalo
155 Biomedical Education Building 3435 Main Street Erie Buffalo
3 Gates Circle Erie Buffalo
127 North Street Genesee Batavia
3435 Main Street Hayes Annex A Erie Buffalo
207 Foote Avenue Chautauqua Jamestown
189 East Main Street Chautauqua Westfield
400 North Main Street Wyoming Warsaw
845 Routes 5 & 20 Chautauqua Irving
10. State 11. ZIP 12. Phone 13. Fax 14. Email
NY 14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
NY 14048 716-366-1111 716-363-7239 rketcham@brookshospital.org
NY 14214 716-862-2400 716-862-2468 pcapelli@chsbuffalo.org
NY 14432 315-462-0254 315-462-3492 david.markant@cshosp.com
NY 14810 607-776-8501 607-776-8817 ceojbw@idmh.org
NY 14215 716-898-3000 716-898-5650 myoung@ecmc.edu
NY 14451 315-483-1199 315-483-2451 maryz@flmhcp.org
NY 14456 315-781-8448 315-781-8444 maryz@flmhcp.org
NY 13160 315-776-9700 315-776-9701 maryz@flmhcp.org
NY 14456 315-787-4000 315-787-4029 jim.dooley@flhealth.org
NY 14895 585-593-1100 585-596-4005 brucknerb@jmhny.org
NY 14203 716-859-2732 716-859-3323 EBauerlein@kaleidahealth.org
NY 14420 585-395-6095 585-395-6007 jschrenker@lakesidehealth.org
NY 14103 585-798-2000 585-798-8444 jsinner@medinamemorial.org
NY 14092 716-298-2173 419-844-6157 Richard.Witowksi@msmh.org
NY 14302 716-278-4000 716-278-4054 anthony.zito@nfmmc.org
NY 14437 585-335-6001 585-335-5881 jwissler@noyes-hospital.org
NY 14420 585-637-3905 585-637-4990 dfisher@oochc.org
NY 14098 585-637-3905 585-637-4990 dfisher@oochc.org
NY 14411 585-589-5613 585-589-0872 dfisher@oochc.org
NY 14411 585-589-4519 585-637-4990 dfisher@oochc.org
NY 14760 716-373-2600 716-345-6394 tfinan@ogh.org
NY 14095 716-433-4427 716-831-1065 karen.nelson@ppwny.org
NY 14301 716-282-1223 716-831-1065 karen.nelson@ppwny.org
NY 14610 585-922-1651 585-922-1655 david.kamowski@viahealth.org
NY 14865 607-535-7121 607-535-9097 stelzerr@schuylerhospital.org
NY 14843 607-324-8113 607-324-8960 mlarowe@sjmh.org
NY 14901 607-633-6541 607-737-7837 mcastagnaro@stjosephs.org
NY 14701 716-661-1412 trcpaulcesana@alltel.net
NY 14424 585-396-6490 585-396-6477 deborah.weymouth@thompsonhealth.org
NY 14070 716-951-7034 716-532-8901 lfrascella@tlchealth.org
NY 14215 716-898-4328 716-898-3024 asaltzma@buffalo.edu
NY 14215 716-898-4744 716-898-4750 duttgeka@buffalo.edu
NY 14214 716-829-2975 716-829-2915 jkmiller@buffalo.edu
NY 14209 716-887-5200 Mkedron@buffns.com
NY 14020 585-344-5456 585-344-7434 mschoell@ummc.org
NY 14214 716-829-3670 716-829-3514 mrogers5@buffalo.edu
NY 14702 716-487-0141 716-664-8336 betsy.wright@wcahospital.org
NY 16544 716-326-4921 716-326-3802 abontem@svhs.org
NY 14569 585-786-8940 585-786-1222 rkrawiec@wcchs.net
NY 14081 716-951-7000 716-951-7046 lfrascella@tlchealth.org
15. Mailing Address 16a. Mailing Contact, First Name
2: No, go to Block 3 (26)
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
1: Yes, complete Block 2 (16-25) Kenneth
16b. Mailing Contact, Middle Initial 16c. Mailing Contact, Last Name
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
L Oakley, PhD, FACHE
17. Mailing Organization 18. Mailing Address Line 1
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
WNY Rural Area Health Education Center 20 Duncan Street
19. Mailing Address Line 2 20. Mailing City 21. HCP Mailing Address State
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
PO BOX 152 Warsaw NY
22. Mailing ZIP 23. Mailing Phone 24. Mailing Fax 25. Mailing Email
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
14569 585-786-6275 585-786-6280 wnyrbhn@r-ahec.org
26. Funding Year 27a. Eligible Entity?
3: Year 2009 (7/1/2009: 6/30/2010) No
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
3: Year 2009 (7/1/2009: 6/30/2010) Yes
27b. Eligible Entity Type
11: Other (ineligible) entity
5: Not-for-profit hospital
5: Not-for-profit hospital
5: Not-for-profit hospital
5: Not-for-profit hospital
5: Not-for-profit hospital
2: Community health center or health center providing health to migrants
2: Community health center or health center providing health to migrants
2: Community health center or health center providing health to migrants
5: Not-for-profit hospital
5: Not-for-profit hospital
5: Not-for-profit hospital
5: Not-for-profit hospital
5: Not-for-profit hospital
5: Not-for-profit hospital
5: Not-for-profit hospital
5: Not-for-profit hospital
2: Community health center or health center providing health to migrants
2: Community health center or health center providing health to migrants
2: Community health center or health center providing health to migrants
2: Community health center or health center providing health to migrants
5: Not-for-profit hospital
10: Urban Health Clinic
10: Urban Health Clinic
5: Not-for-profit hospital
5: Not-for-profit hospital
5: Not-for-profit hospital
5: Not-for-profit hospital
6: Rural health clinic
5: Not-for-profit hospital
5: Not-for-profit hospital
1: Post-secondary educational institution offering health care instruction, teaching hospital or medical school
1: Post-secondary educational institution offering health care instruction, teaching hospital or medical school
1: Post-secondary educational institution offering health care instruction, teaching hospital or medical school
1: Post-secondary educational institution offering health care instruction, teaching hospital or medical school
5: Not-for-profit hospital
1: Post-secondary educational institution offering health care instruction, teaching hospital or medical school
5: Not-for-profit hospital
5: Not-for-profit hospital
5: Not-for-profit hospital
6: Rural health clinic
27c. Explanation of Eligibility
Ineligible Entity
In accordance with NYS law, Dept. of Health issued Operating Certificate # 0601000H, and is a non-
profit hospital.
Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; was issued a NYS DOH Operating Certificate 1401013H, 1404000H, and 1401008H
and is a non-profit hospital.
Hospital licensed under New York State Department of Health, in accordance with the New York
State Law, Article 28; NYSDOH Operating Certificate # 342100H, and is a not-for-profit and teaching
hospital
Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate # 5022000H and is a not-for-profit hospital.
Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate # 1401005H and is a not-for-profit and teaching
hospital.
Eligibility for this entity is based upon the fact that they were certified as a Federally Qualified Health
Center as well as providing healthcare to migrants.
Eligibility for this entity is based upon the fact that they were certified as a Federally Qualified Health
Center as well as providing healthcare to migrants.
Eligibility for this entity is based upon the fact that they were certified as a Federally Qualified Health
Center as well as providing healthcare to migrants.
Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate #3402000H and is a not-for-profit hospital.
Hospital licenssed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate #0228000H and is a not-for-profit hospital.
Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate # 1401014H and is a not-for-profit and teaching
hospital.
Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate #2728001H and is a not-for-profit hospital.
Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate # 3622000H and is a not-for-profit hospital.
Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate #3121001H and is a not-for-profit hospital.
Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate #3102000H and is a not-for-profit hospital.
Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate # 2527000H and is a not-for-profit hospital.
Eligibility is based on the fact that they are deemed to be a Federally Qualified Health Center.
Eligibility is based on the fact that they are deemed to be a Federally Qualified Health Center.
Eligibility is based on the fact that they are deemed to be a Federally Qualified Health Center.
Eligibility is based on the fact that they are deemed to be a Federally Qualified Health Center.
Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate #0401001H and is a not-for-profit hospital.
Eligibility is based upon the fact that they are a non-profit health care agency. With an operating
certificate issued by the New York State Department of Health # 1401235R, facility id # 2772
Eligibility is based upon the fact that they are a non-profit health care agency. With an operating
certificate issued by the New York State Department of Health # 1401235R, facility id # 576
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 2701003H.
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 48237000C
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 5002001H and is a not-for-profit hospital.
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 1455000H
Eligibility is based upon the fact that they are a non-profit health care agency, with an operating
certificate issued by the NYS Department of Health # 060221R
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 3429000H
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 0427000H and is a not-for-profit hospital.
Teaching facility for medical Residency training programs leading to M.D. degree in Internal
Medicine offered by UB School of Medicine & Biomedical Sciences. Clinical faculty at the facility also
contribute to academic Ph.D. programs.
Teaching facility for medical Residency training programs leading to M.D. degree in Family Medicine
offered by UB School of Medicine & Biomedical Sciences. Clinical faculty at the facility also
contribute to academic Ph.D. programs.
Nationally-accredited School of Medicine and Biomedical Scineces with formal medical and nursing
educationalprograms leading to M.D., BSN and MSN degrees. Complete list of clinical educational
programs found at the link: http://www.smbs.buffalo.edu/education.php
Teaching facility for medical Residency training programs leading to M.D. degree in Neurosurgery
offered by UB School of Medicine & Biomedical Sciences. Clinical faculty at the facility also
contribute to academic Ph.D. programs.
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 1801000H
Teaching facility for medical Residency training programs leading to M.D. degree in Orthopedics
offered by UB School of Medicine & Biomedical Sciences. Clinical faculty at the facility also
contribute to academic Ph.D. programs.
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 0602001H and is a not-for-profit hospital.
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 0632000H
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 6027000H and is a not-for-profit hospital.
Health Clinic licensed under New York State Department of Health, in acccordance with New York
State Law, Article 28: NYSDOH Operating Certificate # 0427000H and is a not-for-profit rural health
clinic.
28. Description of Consortium, Dedicated ER Dept or Part-Time
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
29: Description of Telecom/Internet Services
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
31. Certify authorized to submit request for HCP?
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
32. Certify HCP followed state or local procurement rules?
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
33. Certify will utilize telecom services for health care?
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
34. Certify that HCP is nonprofit or public entity?
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
35. Certify that HCP is located in a rural area?
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
TRUE
36. Certify that HCP satisfies all requirements? 38. Date
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
TRUE 6/24/2009
39a. Authorized Person, First Name 39b. Authorized Person, Middle Initial
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
Kenneth L
39c. Authorized Person, Last Name 40. Title or Position
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
Oakley, PhD, FACHE CEO
41. Employer 42. Employer's FCC RN
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
Western New York Rural Area Health Education Center 0017512393
