Basic Information
| Provider Information | |||||||||
| NPI: | 1720009871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEAVITT | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 SALINA MEADOWS PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132124516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154642000 | ||||||||
| FaxNumber: | 3154642010 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 IRVING AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645533 | ||||||||
| FaxNumber: | 8028478158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 06/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 168144 | NY | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 042-0007764 | VT | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 01087365 | 05 | NY | MEDICAID |