1073988911 NPI number — UPSTATE FAMILY AND PREVENTIVE MEDICINE, INC

Table of content: DR. EDITHA ANGELITA PANGAN MD (NPI 1720165749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073988911 NPI number — UPSTATE FAMILY AND PREVENTIVE MEDICINE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UPSTATE FAMILY AND PREVENTIVE MEDICINE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
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NPI Number Information

NPI Number:
1073988911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
251 SALINA MEADOWS PKWY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-464-2014
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
475 IRVING AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-464-4686
Provider Business Practice Location Address Fax Number:
315-464-7106
Provider Enumeration Date:
12/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
EPLING
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHAIRMAN
Authorized Official Telephone Number:
315-464-4686

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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