Provider Demographics
NPI:1013977495
Name:O'NEILL-HUBER, MARY LOU (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:O'NEILL-HUBER
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 1:600 RED CREEK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-4300
Mailing Address - Country:US
Mailing Address - Phone:585-222-6566
Mailing Address - Fax:585-225-5505
Practice Address - Street 1:121 ERIE CANAL DR
Practice Address - Street 2:SUITE B
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4605
Practice Address - Country:US
Practice Address - Phone:585-225-5420
Practice Address - Fax:585-225-5644
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205258208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5795663OtherAETNA
NYMDB767OtherPREFERRED CARE
NY01740234Medicaid
NYP010205258OtherBLUES
NYMDB767OtherPREFERRED CARE