Provider Demographics
NPI:1487252581
Name:NORTH SHORE MEDICAL GROUP PLLC
Entity type:Organization
Organization Name:NORTH SHORE MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA
Authorized Official - Prefix:
Authorized Official - First Name:JOSHU
Authorized Official - Middle Name:
Authorized Official - Last Name:COPPOLA
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:315-289-6300
Mailing Address - Street 1:311 SKYVIEW TER
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-2835
Mailing Address - Country:US
Mailing Address - Phone:315-935-1154
Mailing Address - Fax:952-209-2012
Practice Address - Street 1:311 SKYVIEW TER
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-2835
Practice Address - Country:US
Practice Address - Phone:315-935-1154
Practice Address - Fax:952-209-2012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-12
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty