Healthcare Provider Details

I. General information

NPI: 1730126814
Provider Name (Legal Business Name): MARTHA E TYMESON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 VETERANS AVE BEHAVIORAL HEALTH ROOM 511
BATH NY
14810-0810
US

IV. Provider business mailing address

76 VETERANS AVE BEHAVIORAL HEALTH ROOM 511
BATH NY
14810-0810
US

V. Phone/Fax

Practice location:
  • Phone: 607-664-4300
  • Fax: 607-664-4320
Mailing address:
  • Phone: 607-664-4300
  • Fax: 607-664-4320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number236941
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: