Basic Information
Provider Information | |||||||||
NPI: | 1497788574 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NEUROSURGICAL ASSOCIATES OF CENTRAL NEW YORK, LLP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UPSTATE BRAIN AND SPINE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 750 E ADAMS ST | ||||||||
Address2: | 613 JACOBSEN HALL | ||||||||
City: | SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 132102306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154644470 | ||||||||
FaxNumber: | 3154645520 | ||||||||
Practice Location | |||||||||
Address1: | 725 IRVING AVE | ||||||||
Address2: | SUITE 503 | ||||||||
City: | SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 132101603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154644470 | ||||||||
FaxNumber: | 3154645520 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2006 | ||||||||
LastUpdateDate: | 10/13/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHIN | ||||||||
AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
AuthorizedOfficialTelephone: | 3154644470 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 02223641 | 05 | NY |   | MEDICAID |