Basic Information
| Provider Information | |||||||||
| NPI: | 1770539066 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC SERVICE GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 E. ADAMS ST. | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645450 | ||||||||
| FaxNumber: | 3154647564 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 E. ADAMS ST. | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645450 | ||||||||
| FaxNumber: | 3154647564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 10/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | WELCH | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHAIRMAN OF DEPARTMENT | ||||||||
| AuthorizedOfficialTelephone: | 3154645450 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01215750 | 05 | NY | MEDICAID |