Provider Demographics
NPI:1871710038
Name:SYRACUSE MODEL NEIGHBORHOOD FACILITY, INC
Entity type:Organization
Organization Name:SYRACUSE MODEL NEIGHBORHOOD FACILITY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCIAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:SCHROEDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-435-3295
Mailing Address - Street 1:428 W ONONDAGA ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3210
Mailing Address - Country:US
Mailing Address - Phone:315-435-3295
Mailing Address - Fax:315-435-8242
Practice Address - Street 1:301 SLOCUM AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-3223
Practice Address - Country:US
Practice Address - Phone:315-435-3295
Practice Address - Fax:315-435-8242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00474199Medicaid
NY03003849Medicaid