1851321855 NPI number — DR. LARISA KHISHCHENKO M.D.

Table of content: DR. LARISA KHISHCHENKO M.D. (NPI 1851321855)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851321855 NPI number — DR. LARISA KHISHCHENKO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHISHCHENKO
Provider First Name:
LARISA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1851321855
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
485 TITUS AVE
Provider Second Line Business Mailing Address:
STE H
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14617-3535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-338-2530
Provider Business Mailing Address Fax Number:
585-338-7304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
485 TITUS AVE
Provider Second Line Business Practice Location Address:
STE H
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14617-3535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-338-2530
Provider Business Practice Location Address Fax Number:
585-338-7304
Provider Enumeration Date:
07/04/2006

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: 207R00000X , with the licence number:  180528 , 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: 102621BJ . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01584647 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P010180528 . This is a "BLUE CHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P050180528 . This is a "BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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