Provider Demographics
NPI:1073708756
Name:NORTHSIDE ECHOCARDIOGRAPHY, PC
Entity Type:Organization
Organization Name:NORTHSIDE ECHOCARDIOGRAPHY, PC
Other - Org Name:LAURA J VON DOENHOFF, MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-336-5050
Mailing Address - Street 1:1415 PORTLAND AVE
Mailing Address - Street 2:SUITE 555
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3038
Mailing Address - Country:US
Mailing Address - Phone:585-336-5050
Mailing Address - Fax:585-336-5051
Practice Address - Street 1:1415 PORTLAND AVE
Practice Address - Street 2:SUITE 555
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3038
Practice Address - Country:US
Practice Address - Phone:585-336-5050
Practice Address - Fax:585-336-5051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131660174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY17465BOtherMEDICARE PROVIDER ID#
NY1013967074OtherNPI LAURA J VON DOENHOFF, MD
NYN389329OtherWELLCARE
NYBA1217OtherMEDICARE PTAN
NYMD4G96OtherPREFERRED CARE PROVIDER #
NY00616633Medicaid
NY5309317OtherAETNA
NYP010131660OtherBLUE CHOICE PROVIDER ID
NYP010131660OtherBLUE CHOICE PROVIDER ID