Basic Information
| Provider Information | |||||||||
| NPI: | 1316034960 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELMIRA ORTHOPAEDIC ASSOCIATES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 JOHN ROEMMELT DRIVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | HORSEHEADS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148458302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077951666 | ||||||||
| FaxNumber: | 6077960839 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 JOHN ROEMMELT DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | HORSEHEADS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148458301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077951666 | ||||||||
| FaxNumber: | 6077960839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SAMPSON | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6077951666 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00372005 | 05 | NY | MEDICAID |