Healthcare Provider Details

I. General information

NPI: 1922065093
Provider Name (Legal Business Name): PETER RONAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 08/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MITCHELL AVE NEW HORIZONS
BINGHAMTON NY
13903
US

IV. Provider business mailing address

58 LUSK ST
JOHNSON CITY NY
13790-2541
US

V. Phone/Fax

Practice location:
  • Phone: 607-762-2255
  • Fax:
Mailing address:
  • Phone: 607-763-6293
  • Fax: 607-763-6717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number154048
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: