Healthcare Provider Details

I. General information

NPI: 1902902224
Provider Name (Legal Business Name): INTERNAL MEDICINE ASSOCIATES OF THE SOUTHERN TIER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MADISON AVE
ELMIRA NY
14901-3218
US

IV. Provider business mailing address

200 MADISON AVE
ELMIRA NY
14901-3218
US

V. Phone/Fax

Practice location:
  • Phone: 607-734-1581
  • Fax: 607-767-4109
Mailing address:
  • Phone: 607-734-1581
  • Fax: 607-767-4109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER J RUSSO
Title or Position: DIRECTOR OF INFORMATION SERVICES
Credential:
Phone: 607-734-1581