Provider Demographics
NPI:1427231919
Name:PRACTITIONER SERVICES OF THE SOUTHERN TIER
Entity type:Organization
Organization Name:PRACTITIONER SERVICES OF THE SOUTHERN TIER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JOHANNA
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:607-734-8039
Mailing Address - Street 1:739 LARCHMONT RD
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-1216
Mailing Address - Country:US
Mailing Address - Phone:607-734-8039
Mailing Address - Fax:
Practice Address - Street 1:739 LARCHMONT RD
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1216
Practice Address - Country:US
Practice Address - Phone:607-734-8039
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206255207R00000X
NY331091363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF63753Medicare UPIN
NYIA1057Medicare PIN
NYS74620Medicare UPIN