=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932382199
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAIN TREATMENT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2007
-----------------------------------------------------
Last Update Date | 08/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 ELMWOOD AVE BOX 604
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14642-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-275-5982
-----------------------------------------------------
Fax | 585-756-0169
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 ELMWOOD AVE BOX 604
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14642-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-275-5982
-----------------------------------------------------
Fax | 585-756-0169
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR DIRECTOR OF FINANCE URMFG
-----------------------------------------------------
Name | JILL M HETTERICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 585-756-4003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------