Healthcare Provider Details

I. General information

NPI: 1871513689
Provider Name (Legal Business Name): DEPARTMENT OF MEDICINE MSG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 03/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E GENESEE ST SUITES 205 & 206
SYRACUSE NY
13210-1892
US

IV. Provider business mailing address

1000 E GENESEE ST SUITES 205 & 206
SYRACUSE NY
13210-1892
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-1600
  • Fax: 315-464-1601
Mailing address:
  • Phone: 315-464-1600
  • Fax: 315-464-1601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology 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