Provider Demographics
NPI:1396700985
Name:MAINI, ATUL (MD)
Entity type:Individual
Prefix:
First Name:ATUL
Middle Name:
Last Name:MAINI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 W TAFT RD STE 2E
Mailing Address - Street 2:UPSTATE SURGICAL GROUP P.C.
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-4841
Mailing Address - Country:US
Mailing Address - Phone:315-634-3999
Mailing Address - Fax:315-634-3481
Practice Address - Street 1:5100 W TAFT RD STE 2E
Practice Address - Street 2:UPSTATE SURGICAL GROUP P.C.
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-4841
Practice Address - Country:US
Practice Address - Phone:315-634-3399
Practice Address - Fax:315-634-3481
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002108174400000X
MA239516208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM0000000OtherMEDICARE (PENDING)
NY02586827Medicaid
MA239516OtherMA BORM LICENSE
NY02586827Medicaid
MA239516OtherMA BORM LICENSE