Healthcare Provider Details

I. General information

NPI: 1750547386
Provider Name (Legal Business Name): MARK T. BAESL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 PROSPECT AVE DEPT. OF RADIOLOGY
SYRACUSE NY
13203-1807
US

IV. Provider business mailing address

301 PROSPECT AVE DEPT. OF RADIOLOGY
SYRACUSE NY
13203-1807
US

V. Phone/Fax

Practice location:
  • Phone: 315-703-2138
  • Fax:
Mailing address:
  • Phone: 315-703-2138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD438193
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD438193
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number25MA08811900
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number260730
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number260730
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: