Basic Information
| Provider Information | |||||||||
| NPI: | 1164705224 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLINICAL CAMPUS MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 ROBINSON ST | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139041735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077723535 | ||||||||
| FaxNumber: | 6077723536 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 ROBINSON ST | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139041735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077723535 | ||||||||
| FaxNumber: | 6077723536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2011 | ||||||||
| LastUpdateDate: | 10/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | BORIS | ||||||||
| AuthorizedOfficialFirstName: | LENORE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSOCIATE DEAN | ||||||||
| AuthorizedOfficialTelephone: | 6077723535 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | JD, MS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.