Provider Demographics
NPI:1225021785
Name:TERSEGNO, MICHAEL M (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:M
Last Name:TERSEGNO
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 1:5008 BRITTONFIELD PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9248
Mailing Address - Country:US
Mailing Address - Phone:315-234-7600
Mailing Address - Fax:
Practice Address - Street 1:736 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1687
Practice Address - Country:US
Practice Address - Phone:315-470-7551
Practice Address - Fax:315-470-2719
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1629482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01141193Medicaid
NY51617BMedicare PIN
NYE15704Medicare UPIN
NY50121GMedicare PIN
NY01141193Medicaid
NY300045344Medicare PIN