Healthcare Provider Details

I. General information

NPI: 1184378846
Provider Name (Legal Business Name): INTREPID LANE ASC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 INTREPID LN
SYRACUSE NY
13205-2545
US

IV. Provider business mailing address

100 METROPOLITAN PARK DR STE 100
LIVERPOOL NY
13088-5842
US

V. Phone/Fax

Practice location:
  • Phone: 315-870-9370
  • Fax:
Mailing address:
  • Phone: 315-870-9370
  • Fax: 315-870-9364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ELAN SALZHAUER
Title or Position: CMO
Credential: MD
Phone: 315-870-9370