Provider Demographics
NPI:1851465496
Name:PLASTIC & RECONSTRUCTIVE SURGERY OF CNY PC
Entity Type:Organization
Organization Name:PLASTIC & RECONSTRUCTIVE SURGERY OF CNY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-752-0141
Mailing Address - Street 1:6221 STATE ROUTE 31
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-8724
Mailing Address - Country:US
Mailing Address - Phone:315-752-0141
Mailing Address - Fax:315-752-0142
Practice Address - Street 1:475 IRVING AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1756
Practice Address - Country:US
Practice Address - Phone:315-425-7822
Practice Address - Fax:315-425-7885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124408208200000X, 2082S0105X
NY145420208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01019447Medicaid
NY50840AMedicare PIN
NY01019447Medicaid
NYD02185Medicare UPIN