Basic Information
| Provider Information | |||||||||
| NPI: | 1457436065 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERNAL MEDICINE ASSOCIATES OF THE SOUTHERN TIER, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAB | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077341581 | ||||||||
| FaxNumber: | 6077340972 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077341581 | ||||||||
| FaxNumber: | 6077340972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 02/05/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FREY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6077341581 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | NY | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.