Healthcare Provider Details

I. General information

NPI: 1447789565
Provider Name (Legal Business Name): JACKIE MAE ANDERSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. JACKIE MAE GRIMES

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 07/07/2023
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-4200
US

IV. Provider business mailing address

601 ELMWOOD AVENUE BOX 655
ROCHESTER NY
14642-8655
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-9555
  • Fax: 585-473-3516
Mailing address:
  • Phone: 585-273-4398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberOT018082
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number312232
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number312232
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: