MEDICARE: RETINA SPECIALIST OF THE FINGER LAKES

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	207W00000X	Ophthalmology Physician	199170	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G0189901590	OTHER		BLUE CHOICE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124012802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RETINA SPECIALIST OF THE FINGER LAKES

Provider Business Mailing Address
First Line	:	2300 BUFFALO RD
Second Line	:	BLDG 700B
City	:	ROCHESTER
State	:	NY
Zip	:	14624-1360
Country	:	US
Telephone Number	:	585-254-2260
Fax Number	:	585-254-4035

Provider Business Practice Location Address
First Line	:	2300 BUFFALO RD
Second Line	:	BLDG 700B
City	:	ROCHESTER
State	:	NY
Zip	:	14624-1360
Country	:	US
Telephone Number	:	585-254-2260
Fax Number	:	585-254-4035

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SHI-HWA WILLIAM CHANG
Credential	:	MD
Telephone Number	:	585-254-2260

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	08/22/2020

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