=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104861772
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRICS & ADOLESCENT MEDICINE GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2006
-----------------------------------------------------
Last Update Date | 04/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 ELMWOOD AVE BOX 635
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14642-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-275-7787
-----------------------------------------------------
Fax | 585-275-2352
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 ELMWOOD AVE BOX 635
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14642-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-784-9749
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR DIRECTOR OF FINANCE URMFG
-----------------------------------------------------
Name | JILL M HETTERICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 585-756-4008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0001X
-----------------------------------------------------
Taxonomy Name | Clinical Cardiac Electrophysiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2080A0000X
-----------------------------------------------------
Taxonomy Name | Pediatric Adolescent Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------