Basic Information
| Provider Information | |||||||||
| NPI: | 1184255176 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERNAL MEDICINE GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | URMC HEALTHY LIVING CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 46 PRINCE ST STE 3001 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146071023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855302050 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 46 PRINCE ST STE 3001 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146071023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5856020720 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2020 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HETTERICH | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5857564003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | URMC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1201X | Y | 193200000X MULTI-SPECIALTY GROUP |
No ID Information.