=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205940152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC IMMUN-NEPHR-RHEUMOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2006
-----------------------------------------------------
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 |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 ELMWOOD AVE BOX 635
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14642-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-275-7787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | JILL M HETTERICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 585-756-4008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0201X
-----------------------------------------------------
Taxonomy Name | Pediatric Allergy/Immunology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080P0216X
-----------------------------------------------------
Taxonomy Name | Pediatric Rheumatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2080P0210X
-----------------------------------------------------
Taxonomy Name | Pediatric Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------