Provider Demographics
NPI:1427282771
Name:UPSTATE ORTHOPEDICS AMBULATORY SURGERY CENTER LLC
Entity type:Organization
Organization Name:UPSTATE ORTHOPEDICS AMBULATORY SURGERY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:VAN VALKENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-432-5971
Mailing Address - Street 1:6620 FLY ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057
Mailing Address - Country:US
Mailing Address - Phone:315-432-5960
Mailing Address - Fax:315-432-5979
Practice Address - Street 1:6620 FLY ROAD
Practice Address - Street 2:SUITE 300
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057
Practice Address - Country:US
Practice Address - Phone:315-432-5960
Practice Address - Fax:315-432-5979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-14
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
NY3321200R261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical