Basic Information
| Provider Information | |||||||||
| NPI: | 1114005360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMEDURI | ||||||||
| FirstName: | CLIFFORD | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 RED CREEK DR | ||||||||
| Address2: | STE 120 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146234273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853345560 | ||||||||
| FaxNumber: | 5853345581 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 RED CREEK DR | ||||||||
| Address2: | STE 120 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146234273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853345560 | ||||||||
| FaxNumber: | 5853345581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 11/27/2013 | ||||||||
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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 | 225400000X | 134853-1 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 2084P0800X | 134853-1 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208100000X | 134853-1 | NY | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | BA3459890 | 01 | NY | DEA # | OTHER | 134853-1 | 01 | NY | NEW YORK LICENSE | OTHER |