Provider Demographics
NPI:1639199441
Name:DEPARTMENT OF MEDICINE MEDICAL SERV GRP AT SUNY HLTH SCI CTR AT SYR IN
Entity Type:Organization
Organization Name:DEPARTMENT OF MEDICINE MEDICAL SERV GRP AT SUNY HLTH SCI CTR AT SYR IN
Other - Org Name:INFECTIOUS DISEASE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SRIRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:NARSIPUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-464-3834
Mailing Address - Street 1:725 IRVING AVE
Mailing Address - Street 2:SUITE 311
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1603
Mailing Address - Country:US
Mailing Address - Phone:315-464-5533
Mailing Address - Fax:315-464-5579
Practice Address - Street 1:725 IRVING AVE
Practice Address - Street 2:SUITE 311
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1603
Practice Address - Country:US
Practice Address - Phone:315-464-5533
Practice Address - Fax:315-464-5579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RI0200X
NY332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00459903Medicaid
NY35125AMedicare PIN