Basic Information
| Provider Information | |||||||||
| NPI: | 1639199441 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEPARTMENT OF MEDICINE MEDICAL SERV GRP AT SUNY HLTH SCI CTR AT SYR IN | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | INFECTIOUS DISEASE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 IRVING AVE | ||||||||
| Address2: | SUITE 311 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645533 | ||||||||
| FaxNumber: | 3154645579 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 IRVING AVE | ||||||||
| Address2: | SUITE 311 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645533 | ||||||||
| FaxNumber: | 3154645579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 03/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | NARSIPUR | ||||||||
| AuthorizedOfficialFirstName: | SRIRAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3154643834 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | NY | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207RI0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 00459903 | 05 | NY | MEDICAID |