Basic Information
| Provider Information | |||||||||
| NPI: | 1144310632 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMOLLER | ||||||||
| FirstName: | BRUCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVENUE | ||||||||
| Address2: | URMC BOX 626 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852753184 | ||||||||
| FaxNumber: | 5852762047 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | UNIVERSITY OF ROCHESTER MEDICAL CENTER, BOX 626 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852753184 | ||||||||
| FaxNumber: | 5852762047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
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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 | 207ZD0900X | E-1327 | AR | N | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZP0102X | E-1327 | AR | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZD0900X | 168963-1 | NY | Y | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZD0900X | 042.0012190 | VT | N | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology |
ID Information
| ID | Type | State | Issuer | Description | 131598001 | 05 | AR | MEDICAID | 220019705 | 01 | AR | RAILROAD MEDICARE | OTHER |