Organization
UPSTATE COMMUNITY MEDICAL, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
AMY TUCKER MD (PRESIDENT)
(315) 464-4255
Entity
Organization
Contact information
Practice address
4900 BROAD RD, SYRACUSE, NY 13215-2265
(315) 492-5305
(315) 492-5320
Mailing address
1001 W FAYETTE ST, SUITE 400, SYRACUSE, NY 13204-2859
(315) 472-1488
(315) 883-5407
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
—
—
208600000X
Surgery Physician
—
—
208M00000X
Hospitalist Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02771722
—
NY
01
—
DE7448
RR MEDICARE PIN
NY
Enumeration date
05/26/2006
Last updated
03/03/2021
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