Healthcare Provider Details

I. General information

NPI: 1659754745
Provider Name (Legal Business Name): CORTLAND GI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 EUCLID AVE
CORTLAND NY
13045-1257
US

IV. Provider business mailing address

6 EUCLID AVE
CORTLAND NY
13045-1257
US

V. Phone/Fax

Practice location:
  • Phone: 607-756-9470
  • Fax: 607-756-7048
Mailing address:
  • Phone: 607-756-9470
  • Fax: 607-756-7048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: BOGDAN VATRA
Title or Position: SOLE PROPRIETOR
Credential:
Phone: 607-756-9470