Basic Information
| Provider Information | |||||||||
| NPI: | 1336194265 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CNY GASTROENTEROLOGY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2337 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132202337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154226705 | ||||||||
| FaxNumber: | 3154223909 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 NELSON ST | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130211944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152520810 | ||||||||
| FaxNumber: | 3152525179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 07/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | NIZAM | ||||||||
| AuthorizedOfficialFirstName: | RAYEES | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3152520810 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 02974656 | 05 | NY | MEDICAID |