Basic Information
| Provider Information | |||||||||
| NPI: | 1356309157 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FALKOVICH | ||||||||
| FirstName: | RUVIM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 KINGS HIGHWAY SOUTH | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146175504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859221304 | ||||||||
| FaxNumber: | 5859221399 | ||||||||
| Practice Location | |||||||||
| Address1: | 1425 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146213001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853384941 | ||||||||
| FaxNumber: | 5854674626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 203879 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 050915000065 | 01 | NY | FIDELIS CARE # | OTHER | 00027282401 | 01 | NY | UNIVERA # | OTHER | 00355266 | 05 | NY | MEDICAID | 101666DL | 01 | NY | PREFERRED CARE # | OTHER | 1214011 | 01 | NY | IHA # | OTHER | P010203879 | 01 | NY | BLUE CHOICE # | OTHER |