Healthcare Provider Details

I. General information

NPI: 1124012737
Provider Name (Legal Business Name): RETINA-VITREOUS SURGEONS OF CENTRAL NEW YORK, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 GREENFIELD PKWY
LIVERPOOL NY
13088-6655
US

IV. Provider business mailing address

200 GREENFIELD PKWY
LIVERPOOL NY
13088-6655
US

V. Phone/Fax

Practice location:
  • Phone: 315-445-8166
  • Fax: 315-445-2697
Mailing address:
  • Phone: 315-445-8166
  • Fax: 315-445-2697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANNE SMITH
Title or Position: BUSINESS SERVICES COORDINATOR
Credential:
Phone: 315-445-8166