MEDICARE: THE CHURCH HOME OF THE PROTESTANT EPISCOPAL CHURCH IN THE CITY OF ROCH

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	314000000X	Skilled Nursing Facility	2701339N	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	103363CI	OTHER	NY	PREFERRED CARE - SKILLED
2	3123439	OTHER	NY	AETNA - COMMERCIAL
3	103363XX	OTHER	NY	PREFERRED CARE - CUSTODIA
4	44	OTHER	NY	EXCELLUS BC/BS
5	P014015944	OTHER	NY	BLUE CHOICE THERAPY
6	P015005944	OTHER	NY	BLUE CHOICE ROOM & BOARD
7	103363FQ	OTHER	NY	PREFERRED CARE - THERAPY
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255338117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CHURCH HOME OF THE PROTESTANT EPISCOPAL CHURCH IN THE CITY OF ROCH

Provider Business Mailing Address
First Line	:	505 MOUNT HOPE AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14620-2251
Country	:	US
Telephone Number	:	585-546-8400
Fax Number	:	585-325-6553

Provider Business Practice Location Address
First Line	:	505 MOUNT HOPE AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14620-2251
Country	:	US
Telephone Number	:	585-546-8400
Fax Number	:	585-325-6553

Authorized Official
Title or Position	:	EXECUTIVE VP/CFO
Name	:	MS. LISA J MARCELLO
Credential	:	CPA
Telephone Number	:	585-546-8400

Provider Enumeration Date	:	07/06/2005
Last Update Date	:	05/23/2016

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