Basic Information
| Provider Information | |||||||||
| NPI: | 1366604175 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SYRACUSE COMMUNITY HEALTH CENTER INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 819 S SALINA ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132023527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154767921 | ||||||||
| FaxNumber: | 3152345987 | ||||||||
| Practice Location | |||||||||
| Address1: | 1938 E FAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154767921 | ||||||||
| FaxNumber: | 3152345987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2008 | ||||||||
| LastUpdateDate: | 02/27/2013 | ||||||||
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| AuthorizedOfficialLastName: | ALBRIGO | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3154767921 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SYRACUSE COMMUNITY HEALTH CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 00474204 | 05 | NY | MEDICAID |