Healthcare Provider Details

I. General information

NPI: 1689017329
Provider Name (Legal Business Name): THOMAS JACK WELCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4939 BRITTONFIELD PKWY STE 202
EAST SYRACUSE NY
13057-9208
US

IV. Provider business mailing address

301 PROSPECT AVE
SYRACUSE NY
13203-1807
US

V. Phone/Fax

Practice location:
  • Phone: 315-634-6699
  • Fax: 315-634-6695
Mailing address:
  • Phone: 315-744-1478
  • Fax: 315-744-1218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number294124
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number294124
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: