Provider Demographics
NPI:1326097825
Name:COMMUNITY HOSPITAL MEDICAL GROUP
Entity Type:Organization
Organization Name:COMMUNITY HOSPITAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR OF FINANCE
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 MED
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-6275
Mailing Address - Fax:585-276-2140
Practice Address - Street 1:435 E HENRIETTA RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-4629
Practice Address - Country:US
Practice Address - Phone:585-760-6351
Practice Address - Fax:585-760-6376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16432AMedicare ID - Type UnspecifiedGROUP MEDICARE NUMBER