Healthcare Provider Details

I. General information

NPI: 1346531654
Provider Name (Legal Business Name): SOUTHERN TIER UROLOGY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2011
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3359 LAURIE BROOK DR
BINGHAMTON NY
13903-3153
US

IV. Provider business mailing address

3359 LAURIE BROOK DR
BINGHAMTON NY
13903-3153
US

V. Phone/Fax

Practice location:
  • Phone: 202-636-1131
  • Fax:
Mailing address:
  • Phone: 202-636-1131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number234985
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number234985
License Number StateNY

VIII. Authorized Official

Name: DR. CHRISTOPHER W GIST
Title or Position: DIRECTOR
Credential: MD
Phone: 202-636-1131