Healthcare Provider Details

I. General information

NPI: 1093193120
Provider Name (Legal Business Name): SAMUEL J MACKENZIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2015
Last Update Date: 07/07/2023
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-5718
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 673
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-2559
  • Fax:
Mailing address:
  • Phone: 585-275-2559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number309805
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301107318
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number309805
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: