Basic Information
| Provider Information | |||||||||
| NPI: | 1861496358 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRILLIUM HEALTH, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY HEALTH NETWORK INC, FORMER D/B/A AIDS COMMUNITY HEALTH CENTE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 259 MONROE AVENUE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146073632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855457200 | ||||||||
| FaxNumber: | 5852446456 | ||||||||
| Practice Location | |||||||||
| Address1: | 259 MONROE AVENUE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146073632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855457200 | ||||||||
| FaxNumber: | 5852446456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEMEO | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 5852104103 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 01230991 | 05 | NY | MEDICAID |