Provider Demographics
NPI:1710490263
Name:PODIATRY AFFILIATE OF ROCHESTER PLLC
Entity Type:Organization
Organization Name:PODIATRY AFFILIATE OF ROCHESTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:585-642-6100
Mailing Address - Street 1:1500 PORTLAND AVENUE
Mailing Address - Street 2:PODIATRY SUITE
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3065
Mailing Address - Country:US
Mailing Address - Phone:585-642-6100
Mailing Address - Fax:585-642-6111
Practice Address - Street 1:1500 PORTLAND AVENUE
Practice Address - Street 2:PODIATRY/MEDICAL SUITE
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3065
Practice Address - Country:US
Practice Address - Phone:585-642-6100
Practice Address - Fax:585-642-6111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-07
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05448155Medicaid