Provider Demographics
NPI:1962765016
Name:CENTRAL NEW YORK MEDICAL PRACTICE, PLLC
Entity type:Organization
Organization Name:CENTRAL NEW YORK MEDICAL PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:315-798-4040
Mailing Address - Street 1:1601 ARMORY DR
Mailing Address - Street 2:BUILDING C
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5405
Mailing Address - Country:US
Mailing Address - Phone:315-797-6241
Mailing Address - Fax:315-749-7054
Practice Address - Street 1:600 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3130
Practice Address - Country:US
Practice Address - Phone:315-464-3157
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-22
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty