Healthcare Provider Details

I. General information

NPI: 1285731927
Provider Name (Legal Business Name): ROCHESTER OTOLARYNGOLOGY GROUP PROF CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2561 LAC DE VILLE BLVD SUITE 100
ROCHESTER NY
14618-5645
US

IV. Provider business mailing address

2561 LAC DE VILLE BLVD SUITE 100
ROCHESTER NY
14618-5645
US

V. Phone/Fax

Practice location:
  • Phone: 585-244-3510
  • Fax: 585-244-3519
Mailing address:
  • Phone: 585-244-3510
  • Fax: 585-244-3519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER E MULBURY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 585-244-3510