Provider Demographics
NPI:1871513689
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 1:1000 E GENESEE ST
Mailing Address - Street 2:SUITES 205 & 206
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1892
Mailing Address - Country:US
Mailing Address - Phone:315-464-1600
Mailing Address - Fax:315-464-1601
Practice Address - Street 1:1000 E GENESEE ST
Practice Address - Street 2:SUITES 205 & 206
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1892
Practice Address - Country:US
Practice Address - Phone:315-464-1600
Practice Address - Fax:315-464-1601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RG0100X
NY332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00459903Medicaid
NY35125AMedicare PIN
NY1207540012Medicare NSC