Healthcare Provider Details

I. General information

NPI: 1700297686
Provider Name (Legal Business Name): SCOTT F ULBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 09/14/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 J.B. WISE PLAZA
WATERTOWN NY
13601
US

IV. Provider business mailing address

750 E ADAMS ST
SYRACUSE NY
13210-2306
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-7445
  • Fax: 315-779-1184
Mailing address:
  • Phone: 315-464-3165
  • Fax: 315-464-3178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number290899
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: