Provider Demographics
NPI:1114382280
Name:INTERIM HEALTHCARE OF ROCHESTER
Entity Type:Organization
Organization Name:INTERIM HEALTHCARE OF ROCHESTER
Other - Org Name:INTERIM MENTAL HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTRACT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMBURGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-689-8920
Mailing Address - Street 1:207 HALLOCK RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3033
Mailing Address - Country:US
Mailing Address - Phone:631-689-8920
Mailing Address - Fax:631-689-8955
Practice Address - Street 1:339 EAST AVE
Practice Address - Street 2:STE 303
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14604-2627
Practice Address - Country:US
Practice Address - Phone:585-434-2633
Practice Address - Fax:585-434-2635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-16
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1060L001251E00000X
NY8335001A261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03157426Medicaid