Basic Information
| Provider Information | |||||||||
| NPI: | 1497252563 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ONONDAGA CASE MANAGEMENT SERVICES INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CIRCARE BEHAVIORAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 ERIE BLVD W STE 208 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132042457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154727363 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 620 ERIE BLVD W STE 208 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132042457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154727363 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2018 | ||||||||
| LastUpdateDate: | 04/06/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EBNER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3154727363 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ONONDAGA CASE MANAGEMENT SERVICES INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | 8044025A | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 02717628 | 05 | NY | MEDICAID |