Basic Information
| Provider Information | |||||||||
| NPI: | 1306832084 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JANICKI | ||||||||
| FirstName: | RALPH | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | PHD MD FACC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 E GENESEE ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154711044 | ||||||||
| FaxNumber: | 3154744312 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 E GENESEE ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154711044 | ||||||||
| FaxNumber: | 3154744312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 126330 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | AJ8703387 | 01 | NY | DEA | OTHER | 00558489 | 05 | NY | MEDICAID |