Basic Information
| Provider Information | |||||||||
| NPI: | 1679526669 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRISTIAN D. TVETENSTRAND MD, PLLC | ||||||||
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| OtherOrganizationName: | SOUTHERN TIER SURGICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 HARRISON ST | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077638205 | ||||||||
| FaxNumber: | 6077638208 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HARRISON ST | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077638205 | ||||||||
| FaxNumber: | 6077638208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | TVETENSTRAND | ||||||||
| AuthorizedOfficialFirstName: | CHRISTIAN | ||||||||
| AuthorizedOfficialMiddleName: | DAHN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6077638205 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 011154 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 174400000X | 178438 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 01135079 | 05 | NY | MEDICAID |