Provider Demographics
NPI:1770539066
Name:PEDIATRIC SERVICE GROUP
Entity type:Organization
Organization Name:PEDIATRIC SERVICE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF DEPARTMENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-464-5450
Mailing Address - Street 1:750 E. ADAMS ST.
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210
Mailing Address - Country:US
Mailing Address - Phone:315-464-5450
Mailing Address - Fax:315-464-7564
Practice Address - Street 1:750 E. ADAMS ST.
Practice Address - Street 2:5TH FLOOR
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210
Practice Address - Country:US
Practice Address - Phone:315-464-5450
Practice Address - Fax:315-464-7564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01215750Medicaid
NY56651AMedicare PIN