MEDICARE: BINGHAMTON PODIATRY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104837434
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BINGHAMTON PODIATRY PC

Provider Business Mailing Address
First Line	:	111 E 14TH ST
Second Line	:
City	:	ELMIRA HEIGHTS
State	:	NY
Zip	:	14903-1303
Country	:	US
Telephone Number	:	607-734-9539
Fax Number	:	607-734-6293

Provider Business Practice Location Address
First Line	:	38 FRONT ST
Second Line	:	# 2B
City	:	BINGHAMTON
State	:	NY
Zip	:	13905-4712
Country	:	US
Telephone Number	:	607-724-1263
Fax Number	:	607-724-1263

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	GREG WIXSOM
Credential	:	D.P.M.
Telephone Number	:	607-724-1263

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	02/17/2011

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