Basic Information
| Provider Information | |||||||||
| NPI: | 1184886988 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SYRACUSE COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 819 S. SALINA STREET | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154767921 | ||||||||
| FaxNumber: | 3154751448 | ||||||||
| Practice Location | |||||||||
| Address1: | 2561 ROUTE 11 NORTH | ||||||||
| Address2: | |||||||||
| City: | LA FAYETTE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130849583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154767921 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2008 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | O'CONNOR | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3154767921 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SYRACUSE COMMUNITY HEALTH CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 00474204 | 05 | NY | MEDICAID |