Healthcare Provider Details

I. General information

NPI: 1427053248
Provider Name (Legal Business Name): RUSSELL A ACEVEDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 IRVING AVE
SYRACUSE NY
13210-1687
US

IV. Provider business mailing address

PO BOX 2004
EAST SYRACUSE NY
13057-4504
US

V. Phone/Fax

Practice location:
  • Phone: 315-470-7186
  • Fax: 315-470-2990
Mailing address:
  • Phone: 315-362-5285
  • Fax: 315-445-2936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number145224
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: