MEDICARE: DEPAUL

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417949850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEPAUL

Provider Business Mailing Address
First Line	:	1931 BUFFALO RD
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14624-1535
Country	:	US
Telephone Number	:	585-426-8000
Fax Number	:	585-426-8082

Provider Business Practice Location Address
First Line	:	774 W MAIN ST
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14611-2331
Country	:	US
Telephone Number	:	585-464-8870
Fax Number	:	585-464-8077

Authorized Official
Title or Position	:	VICE PRESIDENT, FINANCE
Name	:	MR. JIM WHALEN
Credential	:
Telephone Number	:	585-426-8000

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

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