Basic Information
| Provider Information | |||||||||
| NPI: | 1336366822 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE UNITY HOSPITAL OF ROCHESTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MENTAL HEALTH OUTPATIENT SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 81 LAKE AVE | ||||||||
| Address2: | EVELYN BRANDON HEALTH CENTER | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146081410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853686900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 81 LAKE AVE | ||||||||
| Address2: | EVELYN BRANDON HEALTH CENTER | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146081410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853686900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STEWART | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT HEATLH CARE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 5857237185 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE UNITY HOSPITAL OF ROCHESTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 14005947 | 01 | NY | BLUE CHOICE | OTHER | 00378721 | 05 | NY | MEDICAID | WM | 01 | NY | BLUE CROSS | OTHER | FA1013 | 01 | NY | PREFERRED CARE | OTHER |