Basic Information
| Provider Information | |||||||||
| NPI: | 1487681219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DISALLE | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1561 LONG POND ROAD | ||||||||
| Address2: | SUITE #206 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853684000 | ||||||||
| FaxNumber: | 5853684815 | ||||||||
| Practice Location | |||||||||
| Address1: | 1561 LONG POND ROAD | ||||||||
| Address2: | SUITE #206 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853684000 | ||||||||
| FaxNumber: | 5853684815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 03/28/2015 | ||||||||
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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 | 207R00000X | 197073 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0002X | 197073 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01658608 | 05 | NY | MEDICAID | 110225075 | 01 | MEDICAID RR | OTHER |