Healthcare Provider Details

I. General information

NPI: 1609941103
Provider Name (Legal Business Name): SOUTHERN TIER OBSTETRICS & GYNECOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 N UNION ST
OLEAN NY
14760
US

IV. Provider business mailing address

PO BOX 564
OLEAN NY
14760
US

V. Phone/Fax

Practice location:
  • Phone: 716-372-2770
  • Fax: 716-372-2740
Mailing address:
  • Phone: 716-372-2770
  • Fax: 716-372-2740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2172551
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02107880
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: FRANK K KWAKYE BERKO
Title or Position: MD
Credential: MD
Phone: 716-372-2770