Provider Demographics
NPI:1083004907
Name:ROGER G LEVINE MD
Entity Type:Organization
Organization Name:ROGER G LEVINE MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:G
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-469-2827
Mailing Address - Street 1:4914 WEST SENECA TURNPKIE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215
Mailing Address - Country:US
Mailing Address - Phone:315-469-2827
Mailing Address - Fax:888-224-8297
Practice Address - Street 1:4914 WEST SENECA TURNPKIE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215
Practice Address - Country:US
Practice Address - Phone:315-469-2827
Practice Address - Fax:888-224-8297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172860323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY51538BMedicare UPIN