Provider Demographics
NPI:1588832984
Name:NANETTE D PHILLIS, MD, PLLC
Entity Type:Organization
Organization Name:NANETTE D PHILLIS, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:OPHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-755-7878
Mailing Address - Street 1:2365 S CLINTON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2663
Mailing Address - Country:US
Mailing Address - Phone:585-461-9500
Mailing Address - Fax:585-271-1432
Practice Address - Street 1:2365 S CLINTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2663
Practice Address - Country:US
Practice Address - Phone:585-461-9500
Practice Address - Fax:585-271-1432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195745261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01563840Medicaid
BA0738Medicare PIN
Y47554Medicare UPIN