Provider Demographics
NPI:1518946599
Name:PETRONE, KIM K (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:K
Last Name:PETRONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 PORTLAND AVENUE
Mailing Address - Street 2:ST ANNS COMMUNITY
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-697-6415
Mailing Address - Fax:585-342-9166
Practice Address - Street 1:1500 PORTLAND AVENUE
Practice Address - Street 2:ST ANNS COMMUNITY
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621
Practice Address - Country:US
Practice Address - Phone:585-697-6415
Practice Address - Fax:585-342-9166
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215418207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
108690BJOtherPREFERRED CARE HERT SAH S
NY02309617Medicaid
RA6962OtherHERITAGE
108690BJOtherPREFERRED CARE HERT SAH S
H58608Medicare UPIN