Basic Information
| Provider Information | |||||||||
| NPI: | 1679531479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUBER | ||||||||
| FirstName: | GEMILA | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HASSAN | ||||||||
| OtherFirstName: | GEMILA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| 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: | 849 PAUL ROAD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5858890740 | ||||||||
| FaxNumber: | 5858890904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 11/30/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 221757 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1292712 | 01 | NY | IHA | OTHER | P010221757 | 01 | NY | BLUE CHOICE | OTHER | 11121694 | 01 | NY | CAQH | OTHER | 00026563702 | 01 | NY | UNIVERA | OTHER | 00355266 | 05 | NY | MEDICAID | 050607000034 | 01 | NY | FIDELIS | OTHER | 109767DL | 01 | NY | PREFERRED CARE | OTHER |