Healthcare Provider Details

I. General information

NPI: 1447212063
Provider Name (Legal Business Name): FAMILYCARE MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W FAYETTE ST STE 400
SYRACUSE NY
13204-2859
US

IV. Provider business mailing address

1001 W FAYETTE ST STE 400
SYRACUSE NY
13204-2859
US

V. Phone/Fax

Practice location:
  • Phone: 315-472-1488
  • Fax: 315-883-5405
Mailing address:
  • Phone: 315-472-1488
  • Fax: 315-883-5405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MITCHELL V BRODEY
Title or Position: PRESIDENT
Credential: MD
Phone: 315-492-5784