Basic Information
| Provider Information | |||||||||
| NPI: | 1851348809 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEPARTMENT OF MEDICINE FACULTY PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1425 PORTLAND AVE | ||||||||
| Address2: | BOX 247 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146213001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859224894 | ||||||||
| FaxNumber: | 5859224440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1425 PORTLAND AVE | ||||||||
| Address2: | BOX 247 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146213001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859224894 | ||||||||
| FaxNumber: | 5859224440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | STERNS | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHEIF OF MEDICINE | ||||||||
| AuthorizedOfficialTelephone: | 5859224234 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0100X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0300X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RH0003X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RN0300X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RP1001X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 204D00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
ID Information
| ID | Type | State | Issuer | Description | 01478431 | 05 | NY | MEDICAID |