Basic Information
Provider Information | |||||||||
NPI: | 1194783415 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLE | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 KINGS HIGHWAY SOUTH | ||||||||
Address2: | PROVIDER ENROLLMENT | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 146175504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5859221304 | ||||||||
FaxNumber: | 5859221399 | ||||||||
Practice Location | |||||||||
Address1: | 1425 PORTLAND AVE | ||||||||
Address2: | WILSON BLDG | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 146212064 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5853381400 | ||||||||
FaxNumber: | 5853399442 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2006 | ||||||||
LastUpdateDate: | 09/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 201580 | NY | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2038 | 01 | NY | SIDNEY HILLMAN | OTHER | 0113576 | 01 | NY | IHA | OTHER | 050922000016 | 01 | NY | FIDELIS | OTHER | P010201580 | 01 | NY | BLUE CHOICE | OTHER | 080100691 | 01 | NY | MEDICARE RAILROAD | OTHER | 11121977 | 01 | NY | CAQH | OTHER | 00355266 | 05 | NY |   | MEDICAID | 101626BF | 01 | NY | PREFERRED CARE | OTHER |