Provider Demographics
NPI:1568428621
Name:MARY M. GOOLEY HEMOPHILIA CENTER INC
Entity Type:Organization
Organization Name:MARY M. GOOLEY HEMOPHILIA CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILMARTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-922-5700
Mailing Address - Street 1:1415 PORTLAND AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3043
Mailing Address - Country:US
Mailing Address - Phone:585-922-5700
Mailing Address - Fax:585-922-5775
Practice Address - Street 1:1415 PORTLAND AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3038
Practice Address - Country:US
Practice Address - Phone:585-922-5700
Practice Address - Fax:585-922-5775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33D0705405261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000921985001OtherBCWNY/HEALTHNOW
NY103346CJOtherPREFERRED CARE
NY00355284Medicaid
NY014005944OtherBLUE CHOICE
NY50OtherBLUE CROSS
NY5643168OtherAETNA
NY00355284Medicaid