1265987325 NPI number — UPSTATE UNIVERSITY CLINICAL CAMPUS MEDICAL GROUP AT BINGHAMTON, INC.

Table of content: (NPI 1265987325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265987325 NPI number — UPSTATE UNIVERSITY CLINICAL CAMPUS MEDICAL GROUP AT BINGHAMTON, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UPSTATE UNIVERSITY CLINICAL CAMPUS MEDICAL GROUP AT BINGHAMTON, INC.
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:
6
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:
1265987325
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
425 ROBINSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BINGHAMTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13904-1735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-772-3516
Provider Business Mailing Address Fax Number:
607-772-3536

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46 HARRISON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13790-2120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-729-6531
Provider Business Practice Location Address Fax Number:
607-217-0110
Provider Enumeration Date:
08/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BORIS
Authorized Official First Name:
LENORE
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
PRACTICE PLAN MANAGER
Authorized Official Telephone Number:
607-772-3516

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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