Provider Demographics
NPI:1518193713
Name:SPECTRUM INTERNAL MEDICINE PLLC
Entity Type:Organization
Organization Name:SPECTRUM INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAYDEN
Authorized Official - Middle Name:RANDLE
Authorized Official - Last Name:GOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:646-246-3674
Mailing Address - Street 1:PO BOX 62
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12789-0062
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1445 PORTLAND AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3036
Practice Address - Country:US
Practice Address - Phone:646-246-3674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226840261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care