=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013977495
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY LOU O'NEILL-HUBER M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2006
-----------------------------------------------------
Last Update Date | 01/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 ERIE CANAL DR SUITE B
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14626-4605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-225-5420
-----------------------------------------------------
Fax | 585-225-5644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 RED CREEK DR STE 200
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14623-4300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-222-6566
-----------------------------------------------------
Fax | 585-225-5505
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 205258
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208C00000X
-----------------------------------------------------
Taxonomy Name | Colon & Rectal Surgery Physician
-----------------------------------------------------
License Number | 205258
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------