MEDICARE: AUBURN MEMORIAL MEDICAL SERVICES, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician
2	207X00000X	Orthopaedic Surgery Physician

General Provider Information

NPI Number	:	1003515800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUBURN MEMORIAL MEDICAL SERVICES, PC

Provider Business Mailing Address
First Line	:	17 LANSING ST
Second Line	:
City	:	AUBURN
State	:	NY
Zip	:	13021-1983
Country	:	US
Telephone Number	:	315-255-7576
Fax Number	:	315-702-8393

Provider Business Practice Location Address
First Line	:	77 NELSON ST STE 120
Second Line	:
City	:	AUBURN
State	:	NY
Zip	:	13021-1941
Country	:	US
Telephone Number	:	315-252-7559
Fax Number	:	315-253-8104

Authorized Official
Title or Position	:	PROVIDER ENROLLMENT SPECIALIST
Name	:	KATHERINE CONWAY-RUSSELL
Credential	:
Telephone Number	:	315-253-1838

Provider Enumeration Date	:	03/01/2023
Last Update Date	:	03/01/2023

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