Healthcare Provider Details

I. General information

NPI: 1972521847
Provider Name (Legal Business Name): MARC L SIDITSKY RPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 PORTLAND AVENUE STE 309
ROCHESTER NY
14621-3008
US

IV. Provider business mailing address

1445 PORTLAND AVENUE STE 309
ROCHESTER NY
14621-3008
US

V. Phone/Fax

Practice location:
  • Phone: 585-342-2638
  • Fax: 585-730-7500
Mailing address:
  • Phone: 585-342-2638
  • Fax: 585-730-7500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000373
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000373-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: