Basic Information
| Provider Information | |||||||||
| NPI: | 1326132499 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STEPHANIE E SIEGRIST MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 980 WESTFALL RD | ||||||||
| Address2: | BLDG. 100, SUITE 105 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146182605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852714272 | ||||||||
| FaxNumber: | 5857306936 | ||||||||
| Practice Location | |||||||||
| Address1: | 980 WESTFALL RD | ||||||||
| Address2: | BLDG. 100, SUITE 105 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146182605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852714272 | ||||||||
| FaxNumber: | 5857306936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SENATOR | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5852714272 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 199450 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01685432 | 05 | NY | MEDICAID |