1104151703 NPI number — SOUTHERN TIER HEARING SERVICES PLLC

Table of content: (NPI 1104151703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104151703 NPI number — SOUTHERN TIER HEARING SERVICES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN TIER HEARING SERVICES PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104151703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
231 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
VESTAL
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13850-1523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-205-1041
Provider Business Mailing Address Fax Number:
607-239-5156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
231 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
VESTAL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13850-1523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-205-1041
Provider Business Practice Location Address Fax Number:
607-239-5156
Provider Enumeration Date:
10/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GLASER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
ARI
Authorized Official Title or Position:
AUDIOLOGIST/OWNER
Authorized Official Telephone Number:
607-205-1041

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  002018-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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