Healthcare Provider Details

I. General information

NPI: 1215592555
Provider Name (Legal Business Name): GEORGE THATVIHANE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE # 655
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

112 ROBERT MICHAELS RUN
PENFIELD NY
14526-9584
US

V. Phone/Fax

Practice location:
  • Phone: 585-463-2940
  • Fax:
Mailing address:
  • Phone: 315-741-0778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number313888-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number313888-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: