Healthcare Provider Details

I. General information

NPI: 1548623002
Provider Name (Legal Business Name): PHILLIP JOHN GARY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 PRESIDENTIAL PLAZA 2ND FL
SYRACUSE NY
13202
US

IV. Provider business mailing address

90 PRESIDENTIAL PLAZA 2ND FL
SYRACUSE NY
13202
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-3835
  • Fax: 315-464-3837
Mailing address:
  • Phone: 315-464-3835
  • Fax: 315-464-3837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number321739
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number67353
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number312739
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: