Provider Demographics
NPI:1548579212
Name:CROUSE MEDICAL PRACTICE PLLC
Entity Type:Organization
Organization Name:CROUSE MEDICAL PRACTICE PLLC
Other - Org Name:INTERNIST ASSOCIATES OF CENTRAL NEW YORK CLINICAL LABORATORIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DEC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-701-2550
Mailing Address - Street 1:730 S CROUSE AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1754
Mailing Address - Country:US
Mailing Address - Phone:315-479-5070
Mailing Address - Fax:315-701-2520
Practice Address - Street 1:739 IRVING AVE
Practice Address - Street 2:SUITE 350
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1651
Practice Address - Country:US
Practice Address - Phone:315-479-5070
Practice Address - Fax:315-701-2520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33D0166447291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
J300031503Medicare PIN