Provider Demographics
NPI:1487681219
Name:DISALLE, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DISALLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1561 LONG POND ROAD
Mailing Address - Street 2:SUITE #206
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626
Mailing Address - Country:US
Mailing Address - Phone:585-368-4000
Mailing Address - Fax:585-368-4815
Practice Address - Street 1:1561 LONG POND ROAD
Practice Address - Street 2:SUITE #206
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626
Practice Address - Country:US
Practice Address - Phone:585-368-4000
Practice Address - Fax:585-368-4815
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2015-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197073207R00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01658608Medicaid
110225075OtherMEDICAID RR
RA0168-GRP BA0017Medicare PIN
NY01658608Medicaid
110225075OtherMEDICAID RR
NY01658608Medicaid