Provider Demographics
NPI:1205856093
Name:DEPARTMENT OF MEDICINE MSG
Entity Type:Organization
Organization Name:DEPARTMENT OF MEDICINE MSG
Other - Org Name:MANLIUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:IANNUZZI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-464-4505
Mailing Address - Street 1:102 W SENECA ST
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-2480
Mailing Address - Country:US
Mailing Address - Phone:315-464-9335
Mailing Address - Fax:315-464-9338
Practice Address - Street 1:102 W SENECA ST
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104-2480
Practice Address - Country:US
Practice Address - Phone:315-464-9335
Practice Address - Fax:315-464-9338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00459903Medicaid
NY35125AMedicare PIN