Basic Information
| Provider Information | |||||||||
| NPI: | 1295949964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOMCIK | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BEVEVINO | ||||||||
| OtherFirstName: | COLLEEN | ||||||||
| OtherMiddleName: | JUDE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 278984 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852751200 | ||||||||
| FaxNumber: | 5857565189 | ||||||||
| Practice Location | |||||||||
| Address1: | 919 WESTFALL RD | ||||||||
| Address2: | BLDG. C, SUITE 220 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146182638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852751200 | ||||||||
| FaxNumber: | 5857565189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 07/13/2016 | ||||||||
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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 | 2084N0400X | 01062094A | IN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 090249 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 35.090249 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 2764129 | 05 | OH | MEDICAID | 415044 | 01 | OH | WELLCARE MEDICAID | OTHER | 9442078 | 01 | OH | AETNA | OTHER | 000000532715 | 01 | OH | ANTHEM | OTHER | P00430594 | 01 | OH | RAILROAD MEDICARE | OTHER | 751189 | 01 | OH | BUCKEYE MEDICAID | OTHER | 000000225117 | 01 | OH | UNISON | OTHER |