Healthcare Provider Details

I. General information

NPI: 1790591576
Provider Name (Legal Business Name): SYRACUSE ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2024
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 GREENFIELD PKWY STE 105
LIVERPOOL NY
13088-6673
US

IV. Provider business mailing address

PO BOX 2005
EAST SYRACUSE NY
13057-4505
US

V. Phone/Fax

Practice location:
  • Phone: 315-451-6911
  • Fax:
Mailing address:
  • Phone: 315-362-5129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: ROWENA ILAG-FERGUSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 315-451-6911