Healthcare Provider Details

I. General information

NPI: 1396714945
Provider Name (Legal Business Name): INTERNIST ASSOCIATES OF CENTRAL NEW YORK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 05/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

739 IRVING AVE SUITE 200
SYRACUSE NY
13210-1640
US

IV. Provider business mailing address

739 IRVING AVE SUITE 200
SYRACUSE NY
13210-1640
US

V. Phone/Fax

Practice location:
  • Phone: 315-479-5070
  • Fax: 315-701-2520
Mailing address:
  • Phone: 315-479-5070
  • Fax: 315-701-2520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARY M OONK
Title or Position: HR MANAGER
Credential:
Phone: 315-479-5070