Healthcare Provider Details

I. General information

NPI: 1205940152
Provider Name (Legal Business Name): PEDIATRIC IMMUN-NEPHR-RHEUMOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE BOX 635
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 635
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-7787
  • Fax:
Mailing address:
  • Phone: 585-275-7787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: JILL M HETTERICH
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 585-756-4008