Basic Information
| Provider Information | |||||||||
| NPI: | 1275972622 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ATANACKOVIC | ||||||||
| FirstName: | MILAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 KINGS HIGHWAY SOUTH | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146175504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859220527 | ||||||||
| FaxNumber: | 5859220636 | ||||||||
| Practice Location | |||||||||
| Address1: | 293 UPPER FALLS BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146052184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859220200 | ||||||||
| FaxNumber: | 5859220230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207Q00000X | 285090 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04530489 | 05 | NY | MEDICAID |