MEDICARE: NYSARC INC. ONONDAGA COUNTY CHAPTER

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD1600X	Developmental Disabilities Clinic/Center

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1043397490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NYSARC INC. ONONDAGA COUNTY CHAPTER

Provider Business Mailing Address
First Line	:	600 S WILBUR AVE
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13204-2730
Country	:	US
Telephone Number	:	315-476-7441
Fax Number	:	315-424-6001

Provider Business Practice Location Address
First Line	:	600 S WILBUR AVE
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13204-2730
Country	:	US
Telephone Number	:	315-476-7441
Fax Number	:	315-424-6001

Authorized Official
Title or Position	:	EXECUITIVE DIRECTOR
Name	:	MR. STANFORT J. PERRY
Credential	:
Telephone Number	:	315-476-7441

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	08/22/2007

600 SOUTH WILBUR AVE
SYRACUSE, NY
13204-2730

Practice Phone: 315-476-7441
Practice Fax: 315-476-1582