Provider Demographics
NPI:1710360649
Name:PODIATRY SERVICES OF CENTRAL NEW YORK, PC
Entity Type:Organization
Organization Name:PODIATRY SERVICES OF CENTRAL NEW YORK, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDDIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:EDELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:315-458-1777
Mailing Address - Street 1:514 S BAY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-3627
Mailing Address - Country:US
Mailing Address - Phone:315-458-1777
Mailing Address - Fax:315-458-9661
Practice Address - Street 1:171 GRANT AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021
Practice Address - Country:US
Practice Address - Phone:315-255-0070
Practice Address - Fax:315-255-0073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN002777-1213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY53631AMedicare PIN