Provider Demographics
NPI:1215312160
Name:EARLENE C. SIEBOLD M.D.P.C,
Entity type:Organization
Organization Name:EARLENE C. SIEBOLD M.D.P.C,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EARLENE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SIEBOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-244-5630
Mailing Address - Street 1:880 WESTFALL RD STE A
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2611
Mailing Address - Country:US
Mailing Address - Phone:585-244-5630
Mailing Address - Fax:
Practice Address - Street 1:880 WESTFALL RD
Practice Address - Street 2:SUITE A
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2611
Practice Address - Country:US
Practice Address - Phone:585-244-5630
Practice Address - Fax:585-487-8250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-21
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY156287207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1045398OtherCAQH
NY01093163Medicaid
BB8505OtherPTAN
NY1045398OtherCAQH
1127BMedicare PIN