Healthcare Provider Details

I. General information

NPI: 1053403717
Provider Name (Legal Business Name): PLASTIC SURGERY GROUP OF ROCHESTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 LINDEN OAKS STE 310
ROCHESTER NY
14625-2814
US

IV. Provider business mailing address

360 LINDEN OAKS STE 310
ROCHESTER NY
14625-2814
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-5840
  • Fax: 585-586-7558
Mailing address:
  • Phone: 585-922-5840
  • Fax: 585-586-7558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. GAIL J EDWARDS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 585-249-1950