Basic Information
| Provider Information | |||||||||
| NPI: | 1194744854 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | LOUISE | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 322 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146081017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852546480 | ||||||||
| FaxNumber: | 5852541092 | ||||||||
| Practice Location | |||||||||
| Address1: | 322 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146081017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852546480 | ||||||||
| FaxNumber: | 5852541092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 143254 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P010143254 | 01 | NY | BLUE CHOICE ROCHESTER | OTHER | 080075250 | 01 | NY | RAILROAD MEDICARE | OTHER | 143254 | 05 | NY | MEDICAID | 100920BF | 01 | NY | PREFERRED CARE | OTHER | 01258268 | 05 | NY | MEDICAID | 6559 | 01 | NY | BLUE CROSS ROCHESTER | OTHER |