Provider Demographics
NPI:1619947843
Name:SYRACUSE GASTROENTEROLOGICAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:SYRACUSE GASTROENTEROLOGICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DONA
Authorized Official - Suffix:
Authorized Official - Credentials:OFFICE MANAGER
Authorized Official - Phone:315-234-4815
Mailing Address - Street 1:739 IRVING AVE.
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210
Mailing Address - Country:US
Mailing Address - Phone:315-234-4815
Mailing Address - Fax:315-234-4805
Practice Address - Street 1:739 IRVING AVE.
Practice Address - Street 2:SUITE 400
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210
Practice Address - Country:US
Practice Address - Phone:315-234-4815
Practice Address - Fax:315-234-4805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00440157Medicaid
NY34594AMedicare ID - Type Unspecified
NYAA0363Medicare ID - Type Unspecified