Basic Information
| Provider Information | |||||||||
| NPI: | 1891729810 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENESEE VALLEY GROUP HEALTH ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LIFETIME HEALTH MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 CARTER STREET | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853394793 | ||||||||
| FaxNumber: | 5853364845 | ||||||||
| Practice Location | |||||||||
| Address1: | 3045 EAST AVENUE | ||||||||
| Address2: | CENTRAL SQUARE HEALTH CENTER | ||||||||
| City: | CENTRAL SQUARE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3156762935 | ||||||||
| FaxNumber: | 3156716976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 09/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | CARLASCIO | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT REGIONAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5853361400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 00355266 | 05 | NY | MEDICAID |