Provider Demographics
NPI:1851463491
Name:LAVINE, PHILIP R (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:R
Last Name:LAVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 C WHITE SPRUCE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1608
Mailing Address - Country:US
Mailing Address - Phone:585-424-6460
Mailing Address - Fax:585-424-5434
Practice Address - Street 1:211 C WHITE SPRUCE BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1608
Practice Address - Country:US
Practice Address - Phone:585-424-6460
Practice Address - Fax:585-424-5434
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1761772084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
11123213OtherCAQH
NY11950BMedicare ID - Type Unspecified
F09997Medicare UPIN