Provider Demographics
NPI:1700994522
Name:ELY, GARNETTA MCCOY (MD)
Entity Type:Individual
Prefix:
First Name:GARNETTA
Middle Name:MCCOY
Last Name:ELY
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 1:12 SAVANNAH CT
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3170 WEST ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1712
Practice Address - Country:US
Practice Address - Phone:585-396-6190
Practice Address - Fax:585-396-6191
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157013207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01577664Medicaid
NYP010157013OtherEXCELLUS
NY101048CDOtherPREFERRED CARE
NY101048CDOtherPREFERRED CARE
NYCC1668Medicare ID - Type Unspecified