Healthcare Provider Details

I. General information

NPI: 1962765016
Provider Name (Legal Business Name): CENTRAL NEW YORK MEDICAL PRACTICE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 11/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E GENESEE ST
SYRACUSE NY
13202-3130
US

IV. Provider business mailing address

1601 ARMORY DR BUILDING C
UTICA NY
13501-5405
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-3157
  • Fax:
Mailing address:
  • Phone: 315-797-6241
  • Fax: 315-749-7054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT MYERS
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD
Phone: 315-798-4040