Basic Information
| Provider Information | |||||||||
| NPI: | 1528146453 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PANORAMA PEDIATRIC GROUP, RLLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 LINDEN OAKS | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853814982 | ||||||||
| FaxNumber: | 5853811821 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 LINDEN OAKS | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853814982 | ||||||||
| FaxNumber: | 5853811821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 04/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | SHIPLEY | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5853814982 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00458113 | 05 | NY | MEDICAID |