Provider Demographics
NPI:1497057624
Name:CECIL J HAGGERTY JR MD PC
Entity Type:Organization
Organization Name:CECIL J HAGGERTY JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAGGERTY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD PC
Authorized Official - Phone:585-637-3010
Mailing Address - Street 1:77 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1305
Mailing Address - Country:US
Mailing Address - Phone:585-637-3010
Mailing Address - Fax:585-637-4919
Practice Address - Street 1:77 WEST AVE
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1305
Practice Address - Country:US
Practice Address - Phone:585-637-3010
Practice Address - Fax:585-637-4919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112867174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00428799Medicaid
NY10406BMedicare PIN
NY871804Medicare UPIN