=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891382123
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPSTATE MEDICAL PROFESSIONALS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2020
-----------------------------------------------------
Last Update Date | 12/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1810 ERIE BLVD E
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13210-1230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-552-1050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1810 ERIE BLVD E
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13210-1230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-552-1050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MEDICAL OFFICER
-----------------------------------------------------
Name | DR. DEREK ROBERT COONEY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 315-552-1050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------