1619948288 NPI number — TIOGA HEALTHCARE PROVIDERS INC-6

Table of content: (NPI 1619948288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619948288 NPI number — TIOGA HEALTHCARE PROVIDERS INC-6

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIOGA HEALTHCARE PROVIDERS INC-6
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:
CANYON SURGICAL ASSOCIATES
Provider Other Organization Name Type Code:
3
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:
1619948288
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 191
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WELLSBORO
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16901-0191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-723-0716
Provider Business Mailing Address Fax Number:
570-723-0638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WELLSBORO
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16901-1601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-723-0716
Provider Business Practice Location Address Fax Number:
570-723-0638
Provider Enumeration Date:
01/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MUDGE
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
570-723-0716

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1626712 . This is a "HIGHMARK BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: DC0711 . This is a "TRAVELERS MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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