Basic Information
| Provider Information | |||||||||
| NPI: | 1922099654 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEBEL | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | ROGER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 IRVING AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645450 | ||||||||
| FaxNumber: | 3154647238 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 IRVING AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645450 | ||||||||
| FaxNumber: | 3154647238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 09/14/2012 | ||||||||
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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 | 207SG0201X | 26339 | SC | N | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | 207SG0201X | 247545 | NY | Y | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) |
ID Information
| ID | Type | State | Issuer | Description | 02987933 | 05 | NY | MEDICAID | 263397 | 05 | SC | MEDICAID |