Provider Demographics
NPI:1730254459
Name:FINGER LAKES MEDICAL GROUP
Entity type:Organization
Organization Name:FINGER LAKES MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-787-5199
Mailing Address - Street 1:200 NORTH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1561
Mailing Address - Country:US
Mailing Address - Phone:315-787-5100
Mailing Address - Fax:315-787-5108
Practice Address - Street 1:200 NORTH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1561
Practice Address - Country:US
Practice Address - Phone:315-787-5100
Practice Address - Fax:315-787-5108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02382869Medicaid
NYAA1479Medicare UPIN