MEDICARE: SYRACUSE UNIVERSITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS1000X	Student Health Clinic/Center

General Provider Information

NPI Number	:	1447338819
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SYRACUSE UNIVERSITY

Provider Business Mailing Address
First Line	:	150 SIMS DR
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13244-2320
Country	:	US
Telephone Number	:	315-443-5698
Fax Number	:	315-443-9010

Provider Business Practice Location Address
First Line	:	150 SIMS DR
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13244-2320
Country	:	US
Telephone Number	:	315-443-5698
Fax Number	:	315-443-9010

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. BENJAMIN DOMINGO
Credential	:	FNP
Telephone Number	:	315-443-9001

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/18/2019

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Directions to “SYRACUSE UNIVERSITY ” Practice Location

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