Healthcare Provider Details

I. General information

NPI: 1497796148
Provider Name (Legal Business Name): GRETCHEN LANO BIRBECK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRETCHEN L DIKE

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 03/21/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE BOX 673
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 278984
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-1200
  • Fax: 585-756-5189
Mailing address:
  • Phone: 585-275-1200
  • Fax: 585-756-5189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number270925
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301075696
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: