Provider Demographics
NPI:1508049032
Name:M R GORIGANTI PHYSICIAN PLLC
Entity Type:Organization
Organization Name:M R GORIGANTI PHYSICIAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHENDER
Authorized Official - Middle Name:RAO
Authorized Official - Last Name:GORIGANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-423-4155
Mailing Address - Street 1:1000 E GENESEE ST STE 100A
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1853
Mailing Address - Country:US
Mailing Address - Phone:315-423-4155
Mailing Address - Fax:315-423-4199
Practice Address - Street 1:1000 E GENESEE ST STE 100A
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1853
Practice Address - Country:US
Practice Address - Phone:315-423-4155
Practice Address - Fax:315-423-4199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210930208100000X, 2081N0008X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02283232Medicaid
NY1144202805OtherPROVIDER NPI
NY=========OtherTAX ID
NY=========OtherTAX ID
NYAA1356Medicare PIN
NY1144202805OtherPROVIDER NPI