MEDICARE: CORAL L. SURGEON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	157602	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	010157602	OTHER	NY	BLUE CHOICE
2	0296919	OTHER	NY	GHI
3	000914977001	OTHER	NY	BC/BS OF WESTERN NEW YORK
4	6184	OTHER	NY	BC/BS
5	000914977003	OTHER	NY	BC/BS OF WESTERN NEW YORK
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	102458CK	OTHER	NY	PREFERRED CARE
8	160009306	OTHER	NY	RAILROAD
9	7849236	OTHER	NY	AETNA
10	000914977002	OTHER	NY	BC/BS OF WESTERN NEW YORK

General Provider Information

NPI Number	:	1073576542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORAL L. SURGEON M.D.

Provider Business Mailing Address
First Line	:	1815 CLINTON AVE S
Second Line	:	SUITE 610
City	:	ROCHESTER
State	:	NY
Zip	:	14618-5720
Country	:	US
Telephone Number	:	585-244-3430
Fax Number	:

Provider Business Practice Location Address
First Line	:	1815 S CLINTON AVE
Second Line	:	SUITE 610
City	:	ROCHESTER
State	:	NY
Zip	:	14618-5720
Country	:	US
Telephone Number	:	585-244-3430
Fax Number	:	585-244-7811

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	07/08/2007

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