Basic Information
| Provider Information | |||||||||
| NPI: | 1710974613 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOVASCULAR SPECIALISTS PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEW YORK HEART CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 10/05/2005 | ||||||||
| LastUpdateDate: | 11/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | GORRA | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3156711400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | C.O.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 00769099 | 05 | NY | MEDICAID |