Provider Demographics
NPI:1275689051
Name:M. GORDON WHITBECK, JR. MD
Entity Type:Organization
Organization Name:M. GORDON WHITBECK, JR. MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:J
Authorized Official - Last Name:KERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-342-2410
Mailing Address - Street 1:2619 CULVER ROAD
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14609
Mailing Address - Country:US
Mailing Address - Phone:585-342-2410
Mailing Address - Fax:585-342-9141
Practice Address - Street 1:2619 CULVER ROAD
Practice Address - Street 2:ST. 2A
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609
Practice Address - Country:US
Practice Address - Phone:585-342-2410
Practice Address - Fax:585-342-9141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167261207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01422691Medicaid
NY01422691Medicaid
NYBA0623Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
NYF34849Medicare UPIN