Provider First Line Business Practice Location Address:
4900 BROAD RD., PHYSICIANS OFFICE BUILDING SOUTH
Provider Second Line Business Practice Location Address:
SUITE 2H
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13215-2265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-492-2520
Provider Business Practice Location Address Fax Number:
315-492-2986
Provider Enumeration Date:
11/17/2005