Provider Demographics
NPI:1396765632
Name:DEPARTMENT OF MEDICINE MSG
Entity type:Organization
Organization Name:DEPARTMENT OF MEDICINE MSG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:IANNUZZI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-464-4505
Mailing Address - Street 1:550 HARRISON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3096
Mailing Address - Country:US
Mailing Address - Phone:315-464-6527
Mailing Address - Fax:315-464-6529
Practice Address - Street 1:550 HARRISON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3096
Practice Address - Country:US
Practice Address - Phone:315-464-6527
Practice Address - Fax:315-464-6529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332B00000X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00459903Medicaid
NY35125AMedicare PIN