1588832984 NPI number — NANETTE D PHILLIS, MD, PLLC

Table of content: (NPI 1588832984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588832984 NPI number — NANETTE D PHILLIS, MD, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NANETTE D PHILLIS, MD, PLLC
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:
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:
1588832984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2365 S CLINTON AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14618-2663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-461-9500
Provider Business Mailing Address Fax Number:
585-271-1432

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2365 S CLINTON AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14618-2663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-461-9500
Provider Business Practice Location Address Fax Number:
585-271-1432
Provider Enumeration Date:
02/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
OPHARDT
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
585-755-7878

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  195745 , 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: 01563840 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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