Basic Information
| Provider Information | |||||||||
| NPI: | 1780828939 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOYAL | ||||||||
| FirstName: | AMIT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 HARRISON ST | ||||||||
| Address2: | SUITE 330 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132023188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154641800 | ||||||||
| FaxNumber: | 3154646252 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 HARRISON ST | ||||||||
| Address2: | SUITE 330 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132023188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154641800 | ||||||||
| FaxNumber: | 3154646252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2009 | ||||||||
| LastUpdateDate: | 10/04/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | A107279 | CA | N | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208C00000X | 248515 | NY | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208600000X | 248515 | NY | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | A107279 | 05 | CA | MEDICAID | 03607701 | 05 | NY | MEDICAID |