Healthcare Provider Details

I. General information

NPI: 1013952688
Provider Name (Legal Business Name): PEDIATRIC ALLERGY OF PULMONARY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
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: 585-275-2352
Mailing address:
  • Phone: 585-275-7787
  • Fax: 585-275-2352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTIN J HAIBACH
Title or Position: CFO
Credential:
Phone: 585-756-4010