Provider Demographics
NPI:1013938174
Name:ASSOCIATED GASTROENTEROLOGISTS OF CENTRAL NEW YORK, PC
Entity type:Organization
Organization Name:ASSOCIATED GASTROENTEROLOGISTS OF CENTRAL NEW YORK, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLUP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-218-0085
Mailing Address - Street 1:260 TOWNSHIP BLVD
Mailing Address - Street 2:STE 20
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031
Mailing Address - Country:US
Mailing Address - Phone:315-708-0091
Mailing Address - Fax:315-708-0194
Practice Address - Street 1:260 TOWNSHIP BLVD
Practice Address - Street 2:STE 20
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031
Practice Address - Country:US
Practice Address - Phone:315-708-0190
Practice Address - Fax:315-488-3284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00482137Medicaid
NYCF1049OtherR/R MEDICARE
NYCC7979OtherR/R MEDICARE
NYCC7979OtherR/R MEDICARE
NY56032AMedicare PIN