Basic Information
| Provider Information | |||||||||
| NPI: | 1205084969 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF ROCHESTER OBGYN SUBSPECIALTIES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE BOX 668 | ||||||||
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| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852755705 | ||||||||
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| Address1: | 601 ELMWOOD AVE | ||||||||
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| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857587671 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2008 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | HETTERICH | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR FINANCE, URMGG | ||||||||
| AuthorizedOfficialTelephone: | 5857564008 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 03158023 | 05 | NY | MEDICAID |