Provider Demographics
NPI:1184897423
Name:ASSOCIATED MEDICAL PROFESSIONALS OF NY, PLLC
Entity type:Organization
Organization Name:ASSOCIATED MEDICAL PROFESSIONALS OF NY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:R
Authorized Official - Last Name:DEROSALIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-458-3343
Mailing Address - Street 1:100 METROPOLITAN PARK DR.
Mailing Address - Street 2:'SUITE 100
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-5842
Mailing Address - Country:US
Mailing Address - Phone:315-870-9370
Mailing Address - Fax:315-558-6611
Practice Address - Street 1:4211 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 211
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6637
Practice Address - Country:US
Practice Address - Phone:315-329-7900
Practice Address - Fax:315-329-7905
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASSOCIATED MEDICAL PROFESSIONALS OF NY, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-08
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6134580002Medicare NSC