Basic Information
| Provider Information | |||||||||
| NPI: | 1114916491 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENRY N CHIONUMA MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2337 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132202337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154222933 | ||||||||
| FaxNumber: | 3154223909 | ||||||||
| Practice Location | |||||||||
| Address1: | 7711 OSWEGO RD | ||||||||
| Address2: | |||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130902322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3156521034 | ||||||||
| FaxNumber: | 3156521493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 09/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | CHIONUMA | ||||||||
| AuthorizedOfficialFirstName: | HENRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3156521034 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02974803 | 05 | NY | MEDICAID |