1760718050 NPI number — MICHAEL RICHARD SACCONE JR. PT

Table of content: MICHAEL RICHARD SACCONE JR. PT (NPI 1760718050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760718050 NPI number — MICHAEL RICHARD SACCONE JR. PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SACCONE
Provider First Name:
MICHAEL
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760718050
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 W FAYETTE ST
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13204-2856
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-472-1488
Provider Business Mailing Address Fax Number:
315-472-8060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 STATE ROUTE 281
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULLY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13159-2494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-696-2400
Provider Business Practice Location Address Fax Number:
315-696-2486
Provider Enumeration Date:
10/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  009432 , 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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