Healthcare Provider Details

I. General information

NPI: 1972769248
Provider Name (Legal Business Name): TARA MARIE PETROSKI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE # 304
ROCHESTER NY
14621
US

IV. Provider business mailing address

1425 PORTLAND AVE # 304
ROCHESTER NY
14621-3095
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-0866
  • Fax: 585-922-2951
Mailing address:
  • Phone: 585-922-0866
  • Fax: 585-922-2951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number253763-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number253763
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: