Basic Information
| Provider Information | |||||||||
| NPI: | 1104884428 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADISON | ||||||||
| FirstName: | COLETTE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHAINTREUIL | ||||||||
| OtherFirstName: | COLETTE | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 800 CARTER STREET | ||||||||
| Address2: | ATTN KELLY STEELE | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853394793 | ||||||||
| FaxNumber: | 5853364845 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 SULLYS TRAIL | ||||||||
| Address2: | |||||||||
| City: | PITTSFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852485300 | ||||||||
| FaxNumber: | 5852483427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 01/14/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0074431 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 970028206 | 01 | NY | MEDICARE RAILROAD # | OTHER | 109289BJ | 01 | NY | PREFERRED CARE # | OTHER | P019007443 | 01 | NY | BLUE CHOICE # | OTHER | 9513997 | 01 | NY | IHA # | OTHER |