Provider Demographics
NPI:1265557995
Name:WEST ONONDAGA PHYSICIANS PC
Entity type:Organization
Organization Name:WEST ONONDAGA PHYSICIANS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-475-5176
Mailing Address - Street 1:659 WEST ONONDAGA ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204
Mailing Address - Country:US
Mailing Address - Phone:315-475-5176
Mailing Address - Fax:315-476-0263
Practice Address - Street 1:659 WEST ONONDAGA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204
Practice Address - Country:US
Practice Address - Phone:315-475-5176
Practice Address - Fax:315-476-0263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119574208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
50530AMedicare ID - Type Unspecified