Basic Information
| Provider Information | |||||||||
| NPI: | 1851873640 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SYRACUSE COMMUNITY HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 819 SOUTH SALINA STREET | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154767921 | ||||||||
| FaxNumber: | 3154751448 | ||||||||
| Practice Location | |||||||||
| Address1: | 819 SOUTH SALINA STREET | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154767921 | ||||||||
| FaxNumber: | 3154751448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2018 | ||||||||
| LastUpdateDate: | 08/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | MURRY | ||||||||
| AuthorizedOfficialFirstName: | DERRICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | EVP/COO | ||||||||
| AuthorizedOfficialTelephone: | 3152345942 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SYRACUSE COMMUNITY HEALTH CENTER, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 03003876 | 05 | NY | MEDICAID | 00474204 | 05 | NY | MEDICAID |