Healthcare Provider Details

I. General information

NPI: 1891382123
Provider Name (Legal Business Name): UPSTATE MEDICAL PROFESSIONALS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 ERIE BLVD E
SYRACUSE NY
13210-1230
US

IV. Provider business mailing address

1810 ERIE BLVD E
SYRACUSE NY
13210-1230
US

V. Phone/Fax

Practice location:
  • Phone: 315-552-1050
  • Fax:
Mailing address:
  • Phone: 315-552-1050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DEREK ROBERT COONEY
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 315-552-1050