Provider Demographics
NPI:1609237304
Name:ST JOSEPH'S MEDICAL PC
Entity Type:Organization
Organization Name:ST JOSEPH'S MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SULIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-744-1865
Mailing Address - Street 1:5100 W TAFT RD
Mailing Address - Street 2:STE 1D
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3807
Mailing Address - Country:US
Mailing Address - Phone:315-744-1865
Mailing Address - Fax:315-744-1954
Practice Address - Street 1:104 UNION AVE
Practice Address - Street 2:STE 1005
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1843
Practice Address - Country:US
Practice Address - Phone:315-424-0790
Practice Address - Fax:315-475-0916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03370858Medicaid
NY03370858Medicaid