Provider Demographics
NPI:1205104262
Name:DEPARTMENT OF MEDICINE MEDICAL SERVICE GROUP
Entity type:Organization
Organization Name:DEPARTMENT OF MEDICINE MEDICAL SERVICE GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:IANNUZZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-464-3835
Mailing Address - Street 1:82 COPELAND AVE
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077-1528
Mailing Address - Country:US
Mailing Address - Phone:607-749-2640
Mailing Address - Fax:607-749-2644
Practice Address - Street 1:82 COPELAND AVE
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:NY
Practice Address - Zip Code:13077-1528
Practice Address - Country:US
Practice Address - Phone:607-749-2640
Practice Address - Fax:607-749-2644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-06
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00459903Medicaid
NY35125AMedicare PIN
NY00459903Medicaid