Basic Information
| Provider Information | |||||||||
| NPI: | 1285059865 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN NEW YORK NEUROSURGICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | EMPIRE STATE NEUROSURGICAL INSTITUTE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 475 IRVING AVE | ||||||||
| Address2: | SUITE 418 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154753999 | ||||||||
| FaxNumber: | 3154754014 | ||||||||
| Practice Location | |||||||||
| Address1: | 475 IRVING AVE | ||||||||
| Address2: | SUITE 418 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154753999 | ||||||||
| FaxNumber: | 3154754014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2014 | ||||||||
| LastUpdateDate: | 02/19/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAJWA | ||||||||
| AuthorizedOfficialFirstName: | SAEED | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6077294942 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 01376512 | 05 | NY | MEDICAID |