Basic Information
| Provider Information | |||||||||
| NPI: | 1669631461 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REEIS-MARTIN | ||||||||
| FirstName: | TALI | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| OtherLastName: | MARTIN | ||||||||
| OtherFirstName: | TALI | ||||||||
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| OtherCredential: | M.D | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 161 RIVERSIDE DR | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139054176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077986700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 134 HOMER AVE | ||||||||
| Address2: | |||||||||
| City: | CORTLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130451206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6074285074 | ||||||||
| FaxNumber: | 6077588210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2008 | ||||||||
| LastUpdateDate: | 03/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 256048 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03186629 | 05 | NY | MEDICAID |