Basic Information
Provider Information | |||||||||
NPI: | 1033289137 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARLIN | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CARLIN | ||||||||
OtherFirstName: | ROBERT | ||||||||
OtherMiddleName: | E | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 104 UNION AVE | ||||||||
Address2: | #1005 | ||||||||
City: | SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 13203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154240790 | ||||||||
FaxNumber: | 3154750916 | ||||||||
Practice Location | |||||||||
Address1: | 104 UNION AVE | ||||||||
Address2: | #1005 | ||||||||
City: | SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 13203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154240790 | ||||||||
FaxNumber: | 3154750916 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2006 | ||||||||
LastUpdateDate: | 07/18/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 2171091 | NY | Y |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
ID | Type | State | Issuer | Description | 02083672 | 05 | NY |   | MEDICAID |