Basic Information
| Provider Information | |||||||||
| NPI: | 1689632986 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SZYMANOWICZ | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| 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: | 800 CARTER STREET | ||||||||
| Address2: | WILSON HEALTH CENTER | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853381400 | ||||||||
| FaxNumber: | 5853364845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010981 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 00355266 | 05 | NY | MEDICAID |