Healthcare Provider Details

I. General information

NPI: 1265488563
Provider Name (Legal Business Name): SYRACUSE ASC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 GREENFIELD PKWY SUITE 105
LIVERPOOL NY
13088-6666
US

IV. Provider business mailing address

225 GREENFIELD PKWY SUITE 105
LIVERPOOL NY
13088-6666
US

V. Phone/Fax

Practice location:
  • Phone: 315-451-6911
  • Fax: 315-451-1540
Mailing address:
  • Phone: 315-451-6911
  • Fax: 315-451-1540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number3331212R
License Number StateNY

VIII. Authorized Official

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