MEDICARE: SYRACUSE UNIVERSITY

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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1912310632
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SYRACUSE UNIVERSITY

Provider Business Mailing Address
First Line	:	804 UNIVERSITY AVE
Second Line	:	SUITE 201
City	:	SYRACUSE
State	:	NY
Zip	:	13244-2340
Country	:	US
Telephone Number	:	315-443-3595
Fax Number	:	315-443-9461

Provider Business Practice Location Address
First Line	:	804 UNIVERSITY AVE
Second Line	:	SUITE 201
City	:	SYRACUSE
State	:	NY
Zip	:	13244-2340
Country	:	US
Telephone Number	:	315-443-3595
Fax Number	:	315-443-9461

Authorized Official
Title or Position	:	TREASURER
Name	:	DAVID J. SMITH
Credential	:
Telephone Number	:	315-443-2486

Provider Enumeration Date	:	06/10/2014
Last Update Date	:	06/10/2014

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Directions to “SYRACUSE UNIVERSITY ” Practice Location

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