Basic Information
| Provider Information | |||||||||
| NPI: | 1629241864 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASSOCIATED MEDICAL PROFESSIONALS OF NY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2000 | ||||||||
| Address2: | ENROLLMENT DEPT | ||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130574500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153625129 | ||||||||
| FaxNumber: | 3153625179 | ||||||||
| Practice Location | |||||||||
| Address1: | 4900 BROAD ROAD SUITE 3K | ||||||||
| Address2: | COMMUNITY GENERAL HOSPITAL POB BUILDING NORTH | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154925882 | ||||||||
| FaxNumber: | 3154925947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2008 | ||||||||
| LastUpdateDate: | 01/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | HOWARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 3154784185 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ASSOCIATED MEDICAL PROFESSIONALS OF NY, PLLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 02922109 | 05 | NY | MEDICAID |