2017-05-15T12:38:59-05:00 2016-06-30 161226221 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2015-07-01 203889761 UPSTATE COMMUNITY MEDICAL PC UPST 3154925940 4900 BROAD ROAD NO 1507 SYRACUSE NY 13215 BONNIE D GROSSMAN MD DIRECTOR 3154925140 2017-05-11 1 ANGELA M FRANCO P00589741 3154463600 2017-05-11 2015 2021-01-29 14:40:06Z BONNIE D GROSSMAN MD 750 EAST ADAMS STREET SYRACUSE NY 13215 13386727 0 X WWW.UPSTATE.EDU/COMMUNITY/UCM/ X 2005 NY THE ROLE OF UPSTATE COMMUNITY MEDICAL, P.C. (UCM) IS TO PROVIDE A COMPREHENSIVE SOURCE FOR ACUTE MEDICAL CARE AND RELATED SERVICES TO ADNVANCE THE MISSION OF UPSTATE MEDICAL UNIVERSITY OF NEW YORK. UCM WAS FORMED FOR THE CHARITABLE PURPOSE OF SERVING THE HEALTH CARE NEEDS OF THE COMMUNITY SERVICED BY THE HOSPITAL AND ADVANCING THE CHARITABLE PURPOSE OF THE UNIVERSITY. 1 0 77 0 0 0 0 0 5880455 13271243 1454 3090 1531 112394 5883440 13386727 0 0 0 0 2962246 7086440 0 0 0 3664212 7906025 6626458 14992465 -743018 -1605738 3456972 4238322 4663833 7030436 -1206861 -2792114 THE ROLE OF UPSTATE COMMUNITY MEDICAL, P.C. IS TO PROVIDE A COMPREHENSIVE SOURCE FOR ACUTE MEDICAL CARE AND RELATED SERVICES TO UNINSURED AND UNDERINSURED INDIVIDUALS IN THE COMMUNITY. 0 0 3740915 3617527 HOSPITALIST SERVICE - PROVIDED ACUTE MEDICAL CARE FOR THE PATIENTS OF UPSTATE UNIVERSITY HOSPITAL COMMUNITY CAMPUS. 1648321 1623817 SURGICAL PHYSICIANS' ASSISTANT SERVICE - PROVIDED SKILLED MEDICAL SERVICES FOR PHYSICIANS PERFORMING SURGICAL PROCEDURES AT THE UPSTATE UNIVERSITY HOSPITAL COMMUNITY CAMPUS. 1502452 1550230 OBGYN HOSPITALIST SERVICE - PROVIDED OB/GYN HEALTHCARE SERVICES TO THE UPSTATE UNIVERSITY HOSPITAL COMMUNITY CAMPUS. 7332079 6592063 7332079 6592063 14223767 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 8 0 1 77 1 0 0 0 0 0 0 0 0 0 0 X 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X ROBERT J CALNON 3154721488 1001 W FAYETTE STREET SYRACUSE NY 13204 X BONNIE GROSSMAN PRESIDENT 40.00 X X 0 0 0 MARY ELLEN GRECO MD PHYSICIAN 40.00 X 311539 0 10600 KRISTINE M KEENEY MD PHYSICIAN 40.00 X 311539 0 10600 ALFREDO LOPEZ MD PHYSICIAN 40.00 X 238854 0 9554 ADAM A THABET PHYSICIANS ASSISTANT 40.00 X 217831 0 0 MARY E VEEDER-CIVITELLO MD PHYSICIAN 40.00 X 217192 0 8717 1296955 0 39471 6 0 1 0 CHAG ANESTHESIA GROUP 5000 BRITTONFIELD PARKWAY EAST SYRACUSE NY 13057 PROFESSIONAL MEDICAL SERVICES 2348569 PRACTICE RESOURCES LLC 1001 W FAYETTE ST SYRACUSE NY 13204 ACCOUNTING AND BILLING 458067 DEPARTMENT OF MEDICINE MEDICAL SERVICE 550 E GENESEE ST SUITE 201 SYRACUSE NY 13202 PROFESSIONAL MEDICAL SERVICES 373397 SYRACUSE ORTHOPEDIC SPECIALIST 5824 WIDEWATERS PARKWAY EAST SYRACUSE NY 13057 PROFESSIONAL MEDICAL SERVICES 208951 SHANE SOPP MD 4900 BROAD ROAD SYRACUSE NY 13215 PROFESSIONAL MEDICAL SERVICES 155122 5 PROFESSIONAL SERVICE AGREEMENT - 621110 9519881 9519881 PROFESSIONAL SERVICES 621110 3751362 3751362 13271243 3090 3090 PROVIDER BASED REVENUE 621110 101100 101100 BAD DEBT RECOVERY 621110 1280 1280 10014 10014 112394 13386727 13383637 0 3090 6094176 5854008 240168 194814 186684 8130 391218 364706 26512 406232 387316 18916 78000 78000 20941 20941 5300 5300 173511 173511 6497 6497 136249 120523 15726 156525 131853 24672 4390 4390 74411 72007 2404 393704 357439 36265 PURCHASED SERVICES 6487506 6487506 BILLING FEES 317905 317905 PERMITS, LICENSES, DUES 23171 23171 27915 27915 14992465 14223767 768698 0 1627597 91772 1726773 3793176 69262 294730 13713 32553 52927 26836 19627 26091 3456972 4238322 3571143 6008953 1092690 1021483 4663833 7030436 X 100 100 0 0 -1206961 -2792214 -1206861 -2792114 3456972 4238322 -1605738 20485 0 X 0 0 0 X 5881986 13271243 19153229 5881986 13271243 19153229 0 0 0 19153229 1454 3090 4544 1454 3090 4544 112394 112394 5883440 13386727 19270167 X 52927 26836 26091 26091 PAYROLL TAXES PAYABLE 32592 LT DEBT 988891 1021483 X X X X X 0 0 0 0 0 0 0 0 0 MARY ELLEN GRECO MD PHYSICIAN 311539 0 0 0 0 0 0 0 10600 0 322139 0 0 0 KRISTINE M KEENEY MD PHYSICIAN 311539 0 0 0 0 0 0 0 10600 0 322139 0 0 0 ALFREDO LOPEZ MD PHYSICIAN 238854 0 0 0 0 0 0 0 9554 0 248408 0 0 0 ADAM A THABET PHYSICIANS ASSISTANT 217831 0 0 0 0 0 0 0 0 0 217831 0 0 0 MARY E VEEDER-CIVITELLO MD PHYSICIAN 217192 0 0 0 0 0 0 0 8717 0 225909 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 A COPY OF FORM 990 WAS DISTRIBUTED FOR REVIEW BEFORE IT WAS FILED. FORM 990, PART VI, SECTION B, LINE 12C EACH DIRECTOR, OFFICER AND MEMBER OF A COMITTEE WITH BOARD DELEGATED POWERS SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS SUCH PERSON HAS READ, UNDERSTANDS, AND HAS COMPLIED WITH THE POLICY. FORM 990, PART VI, SECTION B, LINE 15 BASE SALARY USING COMPARISON DATA AND BONUS OR INCENTIVE COMPENSATION IS BASED ON WRVU ESTABLISHED BY THE FEDERAL GOVERNMENT, TIME, SKILL, AND TRAINING. PERIODIC REVIEWS SHALL BE CONDUCTED REGARDING COMPENSATION AND BENEFIT ARRANGMENTS FOR REASONABLENESS AND CONFORMITY OF CONTRACTS FOR REASONABLE PAYMENT. FORM 990, PART VI, SECTION C, LINE 19 AVAILABLE UPON REQUEST. SUNY UPSTATE UNIVERSITY HOSPITAL 750 E ADAMS STREET SYRACUSE NY 13210 161469571 PATIENT CARE NY 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 SUNY UPSTATE UNIVERSITY HOSPITAL L 9519881 PROFESSIONAL SERVICES AGREEMENT SUNY UPSTATE UNIVERSITY HOSPITAL M 91143 ADMIN SERVICES AGREEMENT