Basic Information
| Provider Information | |||||||||
| NPI: | 1740205566 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF ROCHESTER SURGICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE BOX SURG | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146428410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852751984 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX SURG | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146428410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852751984 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | HETTERICH | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. DIRECTOR OF FINANCE - URMFG | ||||||||
| AuthorizedOfficialTelephone: | 5857564008 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0120X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 2086X0206X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208C00000X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 204F00000X | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Transplant Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01002868 | 05 | NY | MEDICAID | G0183916590 | 01 | NY | BLUE CHOICE | OTHER |