Healthcare Provider Details

I. General information

NPI: 1487252581
Provider Name (Legal Business Name): NORTH SHORE MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 SKYVIEW TER
SYRACUSE NY
13219-2835
US

IV. Provider business mailing address

311 SKYVIEW TER
SYRACUSE NY
13219-2835
US

V. Phone/Fax

Practice location:
  • Phone: 315-935-1154
  • Fax: 952-209-2012
Mailing address:
  • Phone: 315-935-1154
  • Fax: 952-209-2012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSHU COPPOLA
Title or Position: PA
Credential: PA
Phone: 315-289-6300