Basic Information
Provider Information | |||||||||
NPI: | 1598710238 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COHEN | ||||||||
FirstName: | MARK | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 800 CARTER STREET | ||||||||
Address2: | ATTN KELLY STEELE | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 14621 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5853394793 | ||||||||
FaxNumber: | 5853364845 | ||||||||
Practice Location | |||||||||
Address1: | 77 SULLYS TRAIL | ||||||||
Address2: |   | ||||||||
City: | PITTSFORD | ||||||||
State: | NY | ||||||||
PostalCode: | 14534 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5852485300 | ||||||||
FaxNumber: | 5852483427 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 167205 | NY | X |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208000000X | 167205 | NY | X |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 00355266 | 05 | NY |   | MEDICAID | 00025110001 | 01 | NY | UNIVERA | OTHER | 11121974 | 01 | NY | CAQH | OTHER | 2025 | 01 | NY | SIDNEY HILLMAN | OTHER | 050613000028 | 01 | NY | FIDELIS | OTHER | 101150DL | 01 | NY | PREFERRED CARE | OTHER | 0193671 | 01 | NY | IHA | OTHER | 101150BL | 01 | NY | PREFERRED CARE | OTHER |