Healthcare Provider Details

I. General information

NPI: 1780631408
Provider Name (Legal Business Name): INFECTIOUS DISEASE CLINICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE BOX 689
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX MED
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-5871
  • Fax:
Mailing address:
  • Phone: 585-275-0526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: JILL M HETTERICH
Title or Position: SENIOR DIRECTOR OF FINANCE URMFG
Credential:
Phone: 585-756-4008