Provider Demographics
NPI:1336984178
Name:MOSAIC HEALTH, INC.
Entity type:Organization
Organization Name:MOSAIC HEALTH, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSCAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-287-8858
Mailing Address - Street 1:1 S WASHINGTON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14614-1134
Mailing Address - Country:US
Mailing Address - Phone:585-325-2280
Mailing Address - Fax:
Practice Address - Street 1:4100 BALDWIN RD
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:NY
Practice Address - Zip Code:14544-9738
Practice Address - Country:US
Practice Address - Phone:585-287-8844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-25
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00618199Medicaid