Provider Demographics
NPI:1144332818
Name:FISCELLA, KEVIN A (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:FISCELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 CLINTON AVE S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-1401
Mailing Address - Country:US
Mailing Address - Phone:585-279-4800
Mailing Address - Fax:585-442-8319
Practice Address - Street 1:777 CLINTON AVE S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-1401
Practice Address - Country:US
Practice Address - Phone:585-279-4800
Practice Address - Fax:585-442-8319
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY146401207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB71049Medicare UPIN
NYDD3465Medicare PIN