Provider Demographics
NPI:1447338819
Name:SYRACUSE UNIVERSITY
Entity type:Organization
Organization Name:SYRACUSE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:315-443-9001
Mailing Address - Street 1:150 SIMS DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13244-2320
Mailing Address - Country:US
Mailing Address - Phone:315-443-5698
Mailing Address - Fax:315-443-9010
Practice Address - Street 1:150 SIMS DR
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13244-2320
Practice Address - Country:US
Practice Address - Phone:315-443-5698
Practice Address - Fax:315-443-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health