Healthcare Provider Details

I. General information

NPI: 1235183765
Provider Name (Legal Business Name): MEDICAL SPECIALTY GROUP DEPT OF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
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: 585-275-3461
  • Fax: 585-273-1034
Mailing address:
  • Phone: 585-273-1741
  • Fax: 585-756-4968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) 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