Provider Demographics
NPI:1982892006
Name:IMMEDIATE MEDICAL CARE OF CNY, PC
Entity Type:Organization
Organization Name:IMMEDIATE MEDICAL CARE OF CNY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:V
Authorized Official - Last Name:CHMELICEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-682-0909
Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:STE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-472-8060
Practice Address - Street 1:8240 CAZENOVIA RD
Practice Address - Street 2:STE 60
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104-8813
Practice Address - Country:US
Practice Address - Phone:315-682-0909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X
NY240147207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDG7705Medicare PIN
NYBA1280Medicare PIN