Provider Demographics
NPI:1104861772
Name:PEDIATRICS & ADOLESCENT MEDICINE GROUP
Entity Type:Organization
Organization Name:PEDIATRICS & ADOLESCENT MEDICINE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR OF FINANCE URMFG
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:M
Authorized Official - Last Name:HETTERICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-756-4008
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 635
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-784-9749
Mailing Address - Fax:
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX 635
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-7787
Practice Address - Fax:585-275-2352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00485887Medicaid
NY00485887Medicaid