Basic Information
| Provider Information | |||||||||
| NPI: | 1467472217 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEMINO | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 655 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146428655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853413015 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 SOUTH AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146202733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853416880 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 05/24/2011 | ||||||||
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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 | 207P00000X | ME94690 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 207590 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01856606 | 05 | NY | MEDICAID |