Basic Information
| Provider Information | |||||||||
| NPI: | 1730254459 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FINGER LAKES MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | FINGER LAKES MEDICAL ASSOCIATES, LLP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 NORTH ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GENEVA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144561561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157875100 | ||||||||
| FaxNumber: | 3157875108 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 NORTH ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GENEVA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144561561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157875100 | ||||||||
| FaxNumber: | 3157875108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 02/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | RYAN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3157875199 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RN0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02382869 | 05 | NY | MEDICAID |