Healthcare Provider Details

I. General information

NPI: 1851888911
Provider Name (Legal Business Name): ILYA IVYANSKIY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2018
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPARTMENT OF MEDICINE, MEDICAL SERVICE GROUP 1000 E GENESEE ST., SUITE 403
SYRACUSE NY
13210
US

IV. Provider business mailing address

DEPARTMENT OF MEDICINE, MEDICAL SERVICE GROUP 1000 E GENESEE ST., SUITE 403
SYRACUSE NY
13210
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-2929
  • Fax: 315-464-2930
Mailing address:
  • Phone: 315-464-2929
  • Fax: 315-464-2930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC1-0024456
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number343792
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number343792
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: