Provider Demographics
NPI:1245511898
Name:ROCHESTER DIAGNOSTIC AND SPECIALTY CENTER
Entity type:Organization
Organization Name:ROCHESTER DIAGNOSTIC AND SPECIALTY CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PIERRE
Authorized Official - Middle Name:C
Authorized Official - Last Name:ATALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-651-9200
Mailing Address - Street 1:PO BOX 82177
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48308-2177
Mailing Address - Country:US
Mailing Address - Phone:248-651-9200
Mailing Address - Fax:248-651-0355
Practice Address - Street 1:543 N MAIN ST
Practice Address - Street 2:SUITE 211
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1485
Practice Address - Country:US
Practice Address - Phone:248-402-0250
Practice Address - Fax:248-656-3152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076272174400000X
MI4301079362174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F34995Medicare PIN