Provider Demographics
NPI:1912576034
Name:HENRIETTA PEDIATRICS, PLLC
Entity Type:Organization
Organization Name:HENRIETTA PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLICOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:585-451-7014
Mailing Address - Street 1:10 LAWTON DR
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-3266
Mailing Address - Country:US
Mailing Address - Phone:585-451-7014
Mailing Address - Fax:
Practice Address - Street 1:1200 JEFFERSON RD STE 115
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-3158
Practice Address - Country:US
Practice Address - Phone:585-601-2600
Practice Address - Fax:585-229-6008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1801110697Medicaid