=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447565759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | URMC MEMORY CARE PROGRAM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2010
-----------------------------------------------------
Last Update Date | 02/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 SCIENCE PKWY STE 200
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14620-4200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-273-5454
-----------------------------------------------------
Fax | 585-341-7510
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 SCIENCE PKWY STE 200
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14620-4200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-273-5454
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR. DIRECTOR OF FINANCE-URMFG
-----------------------------------------------------
Name | JILL M HETTERICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 585-756-4008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------