MEDICARE: GREECE DERMATOLOGICAL ASSOCIATES, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G0189126590	OTHER	NY	EXCELLUS GROUP ID

General Provider Information

NPI Number	:	1437244498
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREECE DERMATOLOGICAL ASSOCIATES, PC

Provider Business Mailing Address
First Line	:	120 ERIE CANAL DR STE 200
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14626-4609
Country	:	US
Telephone Number	:	585-719-9600
Fax Number	:	585-719-9872

Provider Business Practice Location Address
First Line	:	120 ERIE CANAL DR STE 200
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14626-4609
Country	:	US
Telephone Number	:	585-719-9600
Fax Number	:	585-719-9872

Authorized Official
Title or Position	:	PARTNER
Name	:	MICHAEL BOBROW
Credential	:	MD
Telephone Number	:	585-719-9600

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	11/10/2023

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