Provider Demographics
NPI:1558339473
Name:SYRACUSE UNIVERSITY
Entity Type:Organization
Organization Name:SYRACUSE UNIVERSITY
Other - Org Name:SYRACUSE UNIVERSITY GEBBIE HEARING CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:T
Authorized Official - Last Name:PELLEGRINO
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:315-443-2352
Mailing Address - Street 1:621 SKYTOP RD
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13244-5290
Mailing Address - Country:US
Mailing Address - Phone:315-443-4485
Mailing Address - Fax:315-443-4413
Practice Address - Street 1:621 SKYTOP RD
Practice Address - Street 2:SUITE 1200
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13244-5290
Practice Address - Country:US
Practice Address - Phone:315-443-4485
Practice Address - Fax:315-443-4413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY15000007599231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY55371AMedicare PIN