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General NPI Number Information
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NPI Number | 1245375708
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Entity Type | Organization
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Legal Business Name | IRONDEQUOIT INTERNAL MEDICINE
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Dates
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Enumeration Date | 02/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 485 TITUS AVE STE H
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City | ROCHESTER
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State | NY
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Zip | 14617-3544
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Country | US
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Telephone | 585-338-2530
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Fax | 585-338-7304
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Provider Business Mailing Address
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Address Line | 485 TITUS AVE STE H
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City | ROCHESTER
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State | NY
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Zip | 14617-3544
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Country | US
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Telephone | 585-338-2530
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Fax | 585-338-7304
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Authorized Official
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Title or Position | OWNER
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Name | DR. LARISA KHISHCHENKO
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Credential | M.D.
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Telephone | 585-338-2530
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 180528
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License Number State | NY
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