Provider Demographics
NPI:1083634109
Name:FITZGERALD, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4870 BROAD RD
Mailing Address - Street 2:SUITE 3Q
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215-2206
Mailing Address - Country:US
Mailing Address - Phone:315-492-5292
Mailing Address - Fax:315-492-5123
Practice Address - Street 1:4870 BROAD RD
Practice Address - Street 2:SUITE 3Q
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2206
Practice Address - Country:US
Practice Address - Phone:315-492-5292
Practice Address - Fax:315-492-5123
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1189823207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00482260Medicaid
NY56032CMedicare PIN
NY34944CMedicare ID - Type Unspecified
NYB81343Medicare UPIN