Basic Information
| Provider Information | |||||||||
| NPI: | 1467448951 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROME SURGICAL GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2003 | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130574503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154463904 | ||||||||
| FaxNumber: | 3154452936 | ||||||||
| Practice Location | |||||||||
| Address1: | 7900 TURIN RD | ||||||||
| Address2: | BLDG 2 SUITE 3 | ||||||||
| City: | ROME | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134401900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153370202 | ||||||||
| FaxNumber: | 3153378188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 11/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | BULAWA | ||||||||
| AuthorizedOfficialFirstName: | BETH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3153370202 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01976787 | 05 | NY | MEDICAID |