Provider Demographics
NPI:1689615395
Name:INDEPENDENT PHYSICIANS URGENT CARE PLLC
Entity Type:Organization
Organization Name:INDEPENDENT PHYSICIANS URGENT CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMENIC
Authorized Official - Middle Name:P
Authorized Official - Last Name:AIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-793-8856
Mailing Address - Street 1:PO BOX 8150
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13505-8150
Mailing Address - Country:US
Mailing Address - Phone:315-793-8856
Mailing Address - Fax:315-793-8307
Practice Address - Street 1:1904 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5662
Practice Address - Country:US
Practice Address - Phone:315-793-8856
Practice Address - Fax:315-793-8307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093023207Q00000X
NY140042207Q00000X
NY157472207R00000X
NY171805207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02194645Medicaid
NY02194645Medicaid