Basic Information
| Provider Information | |||||||||
| NPI: | 1134757891 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SYRACUSE PLASTIC SURGERY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3107 E GENESEE ST | ||||||||
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| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132241646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152995313 | ||||||||
| FaxNumber: | 3152995661 | ||||||||
| Practice Location | |||||||||
| Address1: | 3107 E GENESEE ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132241646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152995313 | ||||||||
| FaxNumber: | 3152995661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2020 | ||||||||
| LastUpdateDate: | 03/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | DEROBERTS | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD/ OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3152995313 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| NPICertificationDate: | 03/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.