Healthcare Provider Details

I. General information

NPI: 1396765632
Provider Name (Legal Business Name): DEPARTMENT OF MEDICINE MSG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 10/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 HARRISON ST SUITE 200
SYRACUSE NY
13202-3096
US

IV. Provider business mailing address

550 HARRISON ST SUITE 200
SYRACUSE NY
13202-3096
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-6527
  • Fax: 315-464-6529
Mailing address:
  • Phone: 315-464-6527
  • Fax: 315-464-6529

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 Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNY

VIII. Authorized Official

Name: MICHAEL C. IANNUZZI
Title or Position: PRESIDENT
Credential: MD
Phone: 315-464-4505