1245233295 NPI number — DR. JILL K POTTS M.D.

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	POTTS
Provider First Name	:	JILL
Provider Middle Name	:	K
Provider Name Prefix Text	:	DR.
Provider Name Suffix Text	:
Provider Credential Text	:	M.D.
Provider Gender Code	:	F

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	:	1245233295
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	07/08/2007
NPI Deactivation Reason Code	:
NPI Deactivation Date	:
NPI Reactivation Date	:

Provider First Line Business Mailing Address	:	335 PARRISH ST
Provider Second Line Business Mailing Address	:
Provider Business Mailing Address City Name	:	CANANDAIGUA
Provider Business Mailing Address State Name	:	NY
Provider Business Mailing Address Postal Code	:	144241728
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	5853932845
Provider Business Mailing Address Fax Number	:	5853969275

Provider First Line Business Practice Location Address	:	335 PARRISH ST
Provider Second Line Business Practice Location Address	:
Provider Business Practice Location Address City Name	:	CANANDAIGUA
Provider Business Practice Location Address State Name	:	NY
Provider Business Practice Location Address Postal Code	:	144241728
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	5853932845
Provider Business Practice Location Address Fax Number	:	5853969275
Provider Enumeration Date	:	05/23/2005

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

• Taxonomy code: 207R00000X , with the licence number:  210694 , registered in the state of NY .

• Identifier: 6996 . This is a "BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "".
• Identifier: 01859558 , issued by the state of ( NY ) . This identifiers is of the category "".
• Identifier: G81076 , issued by the state of ( NY ) . This identifiers is of the category "".
• Identifier: MDC741 . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "".
• Identifier: BB2324 , issued by the state of ( NY ) . This identifiers is of the category "".