Basic Information
| Provider Information | |||||||||
| NPI: | 1043205545 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIVECCHI | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2655 RIDGEWAY AVE | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146264285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857237972 | ||||||||
| FaxNumber: | 5853683119 | ||||||||
| Practice Location | |||||||||
| Address1: | 2655 RIDGEWAY AVE | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146264285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857237972 | ||||||||
| FaxNumber: | 5853683119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 02/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 200828 | NY | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P0004X | 200828 | NY | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Spinal Cord Injury Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01892222 | 05 | NY | MEDICAID | P00884039 | 01 | NY | MEDICARE RAILROAD | OTHER |