Provider Demographics
NPI:1053789610
Name:SUNY UPSTATE
Entity type:Organization
Organization Name:SUNY UPSTATE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIKTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:607-759-7462
Mailing Address - Street 1:5104 WATERFORD WOOD WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-9799
Mailing Address - Country:US
Mailing Address - Phone:607-759-7462
Mailing Address - Fax:
Practice Address - Street 1:90 PRESIDENTIAL PLZ
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2240
Practice Address - Country:US
Practice Address - Phone:315-464-3833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339820-1261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center