Provider Demographics
NPI:1386940252
Name:UPSTATE MEDICAL CENTER
Entity type:Organization
Organization Name:UPSTATE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE ANESTHETIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:IMMARRI
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:917-579-8187
Mailing Address - Street 1:7I CREEKSIDE VLG
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14261-0040
Mailing Address - Country:US
Mailing Address - Phone:917-579-8187
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2342
Practice Address - Country:US
Practice Address - Phone:315-464-5654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital