Provider Demographics
NPI:1184716888
Name:MARK ANTOSH MD PC
Entity type:Organization
Organization Name:MARK ANTOSH MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-432-9202
Mailing Address - Street 1:824 FRANKLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-1614
Mailing Address - Country:US
Mailing Address - Phone:315-432-9202
Mailing Address - Fax:315-432-9219
Practice Address - Street 1:824 FRANKLIN PARK DR
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-1614
Practice Address - Country:US
Practice Address - Phone:315-432-1048
Practice Address - Fax:315-432-9219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1061151173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420837Medicaid
NY00572349Medicaid
NY34271CMedicare ID - Type Unspecified
NY00572349Medicaid
NYF57621Medicare UPIN
NYB80998Medicare UPIN