Provider Demographics
NPI:1609865054
Name:AESTHETIC PLASTIC SURGERY OF SYRACUSE PLLC
Entity Type:Organization
Organization Name:AESTHETIC PLASTIC SURGERY OF SYRACUSE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:POTENZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-487-5858
Mailing Address - Street 1:PO BOX 2003
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4503
Mailing Address - Country:US
Mailing Address - Phone:315-446-3904
Mailing Address - Fax:315-445-2936
Practice Address - Street 1:5700 W GENESEE ST
Practice Address - Street 2:SUITE 132
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-3200
Practice Address - Country:US
Practice Address - Phone:315-487-5858
Practice Address - Fax:315-487-1950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA1305Medicare ID - Type Unspecified