Basic Information
| Provider Information | |||||||||
| NPI: | 1427113547 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NYSARC INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 LENOX AVE | ||||||||
| Address2: | |||||||||
| City: | ONEIDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134211500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153639281 | ||||||||
| FaxNumber: | 3153639286 | ||||||||
| Practice Location | |||||||||
| Address1: | 588 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | ONEIDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134212465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153639281 | ||||||||
| FaxNumber: | 3153639286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 07/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEWANDOWSKI | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3153633389 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 01454957 | 05 | NY | MEDICAID |