Provider Demographics
NPI: | 1952305369 |
---|---|
Name: | ALBANESE, STEPHEN A (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | STEPHEN |
Middle Name: | A |
Last Name: | ALBANESE |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 6620 FLY ROAD |
Mailing Address - Street 2: | STE 200 |
Mailing Address - City: | EAST SYRACUSE |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 13057 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 315-464-4472 |
Mailing Address - Fax: | 315-464-5221 |
Practice Address - Street 1: | 6620 FLY ROAD |
Practice Address - Street 2: | STE 200 |
Practice Address - City: | EAST SYRACUSE |
Practice Address - State: | NY |
Practice Address - Zip Code: | 13057 |
Practice Address - Country: | US |
Practice Address - Phone: | 315-464-4472 |
Practice Address - Fax: | 315-464-5221 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-06-13 |
Last Update Date: | 2009-11-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 146522 | 207X00000X, 207XP3100X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207XP3100X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 00961959 | Medicaid | |
NY | 52652H | Medicare PIN | |
NY | 00961959 | Medicaid |