Provider Demographics
NPI:1588711402
Name:OBSTETRIC AND GYNECOLOGIC ASSOC OF CORTLAND MD PC
Entity type:Organization
Organization Name:OBSTETRIC AND GYNECOLOGIC ASSOC OF CORTLAND MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MD
Authorized Official - Prefix:
Authorized Official - First Name:IN WHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-753-7578
Mailing Address - Street 1:11 ALVENA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045
Mailing Address - Country:US
Mailing Address - Phone:607-753-7578
Mailing Address - Fax:607-758-3193
Practice Address - Street 1:11 ALVENA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045
Practice Address - Country:US
Practice Address - Phone:607-753-7578
Practice Address - Fax:607-758-3193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1472741207VG0400X, 207VX0000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02288420Medicaid
NY33D0165489OtherCLIA
NY34655AMedicare ID - Type UnspecifiedGROUP
NY02288420Medicaid