1366494973 NPI number — GREGG BROFFMAN MD

Table of content: GREGG BROFFMAN MD (NPI 1366494973)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366494973 NPI number — GREGG BROFFMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROFFMAN
Provider First Name:
GREGG
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366494973
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 CARTER ST
Provider Second Line Business Mailing Address:
ATTN KELLY STEELE
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-339-4793
Provider Business Mailing Address Fax Number:
585-336-4845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 GARDENVILLE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST SENECA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-668-3600
Provider Business Practice Location Address Fax Number:
716-565-4223
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  131752 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 050216000044 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P00201738 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10520422 . This is a "CAQH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 159628DL . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000089397 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000500324010 . This is a "BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 050216000049 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00010021101 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10495518 . This is a "CAQH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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