Provider Demographics
NPI:1629176755
Name:UPSTATE SURGICAL GROUP PC
Entity Type:Organization
Organization Name:UPSTATE SURGICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:F
Authorized Official - Last Name:CERTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-634-3399
Mailing Address - Street 1:5100 W TAFT RD
Mailing Address - Street 2:STE 2E
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3807
Mailing Address - Country:US
Mailing Address - Phone:315-634-3399
Mailing Address - Fax:315-634-3395
Practice Address - Street 1:5100 W TAFT RD
Practice Address - Street 2:STE 2E
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3807
Practice Address - Country:US
Practice Address - Phone:315-634-3399
Practice Address - Fax:315-634-3395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01408800Medicaid
NY53991AMedicare UPIN
NY6134620001Medicare NSC