Provider Demographics
NPI:1528644705
Name:GREECE PEDIATRIC MEDICINE, PLLC
Entity type:Organization
Organization Name:GREECE PEDIATRIC MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WANIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-504-6504
Mailing Address - Street 1:203 SACKETS LNDG
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-1482
Mailing Address - Country:US
Mailing Address - Phone:585-504-6504
Mailing Address - Fax:585-504-4923
Practice Address - Street 1:3208 LATTA RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-3084
Practice Address - Country:US
Practice Address - Phone:585-504-6504
Practice Address - Fax:585-504-4923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03503766Medicaid