Provider Demographics
NPI:1013021617
Name:UNIVERSITY PEDIATRICS
Entity Type:Organization
Organization Name:UNIVERSITY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:S
Authorized Official - Last Name:STARR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-471-4196
Mailing Address - Street 1:1200 E GENESEE ST
Mailing Address - Street 2:STE 209
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1968
Mailing Address - Country:US
Mailing Address - Phone:315-471-4196
Mailing Address - Fax:315-471-0845
Practice Address - Street 1:1200 E GENESEE ST
Practice Address - Street 2:STE 209
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1968
Practice Address - Country:US
Practice Address - Phone:315-471-4196
Practice Address - Fax:315-471-0845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101656208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01817454Medicaid
NY01817454Medicaid