Provider Demographics
NPI:1396714945
Name:INTERNIST ASSOCIATES OF CENTRAL NEW YORK PC
Entity type:Organization
Organization Name:INTERNIST ASSOCIATES OF CENTRAL NEW YORK PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:OONK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-479-5070
Mailing Address - Street 1:739 IRVING AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1640
Mailing Address - Country:US
Mailing Address - Phone:315-479-5070
Mailing Address - Fax:315-701-2520
Practice Address - Street 1:739 IRVING AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1640
Practice Address - Country:US
Practice Address - Phone:315-479-5070
Practice Address - Fax:315-701-2520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02657330Medicaid
CB0842Medicare PIN
34085AMedicare ID - Type Unspecified
NY02657330Medicaid