Healthcare Provider Details

I. General information

NPI: 1841330073
Provider Name (Legal Business Name): ELLEN MARIE BIFANO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 IRVING AVE RM 9103
SYRACUSE NY
13210-1687
US

IV. Provider business mailing address

736 IRVING AVE RM 9103
SYRACUSE NY
13210-1687
US

V. Phone/Fax

Practice location:
  • Phone: 315-470-7984
  • Fax: 315-470-2923
Mailing address:
  • Phone: 315-470-7984
  • Fax: 315-470-2923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number141219
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: