Provider Demographics
NPI:1184138265
Name:GENESEE STREET MEDICAL HEALTH
Entity type:Organization
Organization Name:GENESEE STREET MEDICAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:MINHAJ
Authorized Official - Middle Name:U
Authorized Official - Last Name:SIDDIQI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-335-4619
Mailing Address - Street 1:286 GENESEE ST STE 5
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-4639
Mailing Address - Country:US
Mailing Address - Phone:315-266-0600
Mailing Address - Fax:315-266-0611
Practice Address - Street 1:286 GENESEE ST STE 5
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502
Practice Address - Country:US
Practice Address - Phone:315-266-0600
Practice Address - Fax:315-266-0611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-28
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2324672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04989199Medicaid