Healthcare Provider Details

I. General information

NPI: 1508049032
Provider Name (Legal Business Name): M R GORIGANTI PHYSICIAN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E GENESEE ST STE 100A
SYRACUSE NY
13210-1853
US

IV. Provider business mailing address

1000 E GENESEE ST STE 100A
SYRACUSE NY
13210-1853
US

V. Phone/Fax

Practice location:
  • Phone: 315-423-4155
  • Fax: 315-423-4199
Mailing address:
  • Phone: 315-423-4155
  • Fax: 315-423-4199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number210930
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number210930
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number210930
License Number StateNY

VIII. Authorized Official

Name: DR. MAHENDER RAO GORIGANTI
Title or Position: MEMBER
Credential: MD
Phone: 315-423-4155