1396158291 NPI number — GENESEE VALLEY GROUP HEALTH

Table of content: (NPI 1396158291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396158291 NPI number — GENESEE VALLEY GROUP HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENESEE VALLEY GROUP HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LIFETIME HEALTH MEDICAL GROUP
Provider Other Organization Name Type Code:
3
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:
1396158291
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 BUTTERNUT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13214-2141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-671-6951
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
470 LONG POND 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:
14612-3057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-227-8322
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2014

Additional Information

Authorized Official

Authorized Official Last Name:
CARLASCIO
Authorized Official First Name:
DEB
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT OF OPERATIONS
Authorized Official Telephone Number:
585-389-6066

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00355266 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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