Provider Demographics
NPI:1073587416
Name:SYRACUSE ENDOSCOPY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:SYRACUSE ENDOSCOPY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KENDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MBA, MSN
Authorized Official - Phone:315-234-6687
Mailing Address - Street 1:739 IRVING AVE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210
Mailing Address - Country:US
Mailing Address - Phone:315-470-5810
Mailing Address - Fax:315-234-4805
Practice Address - Street 1:739 IRVING AVE
Practice Address - Street 2:SUITE 420
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210
Practice Address - Country:US
Practice Address - Phone:315-234-6688
Practice Address - Fax:315-234-4805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3301219261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02691514Medicaid
NY02691514Medicaid