Healthcare Provider Details

I. General information

NPI: 1639533664
Provider Name (Legal Business Name): MR. BRIAN JEFFREY KRAMER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 GRAHAM RD W
ITHACA NY
14850-1055
US

IV. Provider business mailing address

10 GRAHAM RD W
ITHACA NY
14850-1055
US

V. Phone/Fax

Practice location:
  • Phone: 607-257-5958
  • Fax: 607-266-7341
Mailing address:
  • Phone: 607-257-5958
  • Fax: 607-266-7341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number300038
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: