Basic Information
| Provider Information | |||||||||
| NPI: | 1811946825 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENDOCRINE PRACTICE GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE BOX 278911 | ||||||||
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| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857564011 | ||||||||
| FaxNumber: | 5857848367 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 693 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852752901 | ||||||||
| FaxNumber: | 5852731288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 01/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | HETTERICH | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR OF FINANCE, URMFG | ||||||||
| AuthorizedOfficialTelephone: | 5857564003 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | G458104 | 05 | NY | MEDICAID | G0189014590 | 01 | NY | BLCH | OTHER |