Healthcare Provider Details

I. General information

NPI: 1386883569
Provider Name (Legal Business Name): BOURA'A A BOU ARAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2009
Last Update Date: 02/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 IRVING AVENUE SUITE 9100
SYRACUSE NY
13210
US

IV. Provider business mailing address

736 IRVING AVENUE SUITE 9100
SYRACUSE NY
13210
US

V. Phone/Fax

Practice location:
  • Phone: 315-470-7379
  • Fax:
Mailing address:
  • Phone: 315-470-7379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number003282
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: