1316944622 NPI number — M. GORDON WHITBECK JR. M.D.

Table of content: (NPI 1720529621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316944622 NPI number — M. GORDON WHITBECK JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITBECK
Provider First Name:
M.
Provider Middle Name:
GORDON
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
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:
1316944622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 KINGS HWY S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14617-5504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-922-0553
Provider Business Mailing Address Fax Number:
585-922-0496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2619 CULVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14609-1738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-342-2410
Provider Business Practice Location Address Fax Number:
585-342-9141
Provider Enumeration Date:
06/30/2005

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: 207X00000X , with the licence number:  167261 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XS0117X , with the licence number: 167261 , 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: 01422691 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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