=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326110883
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN LAWRENCE CHERUBIM DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2006
-----------------------------------------------------
Last Update Date | 01/02/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 PARK AVE # 181
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14607-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-737-9997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 PARK AVE # 181
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14607-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-737-9997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207PE0004X
-----------------------------------------------------
Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
-----------------------------------------------------
License Number | 201105-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------