Healthcare Provider Details

I. General information

NPI: 1548202971
Provider Name (Legal Business Name): TIOGA HEALTH CARE PROVIDERS INC 4
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32-36 CENTRAL AVE
WELLSBORO PA
16901-1840
US

IV. Provider business mailing address

1699 WASHINGTON RD STE 307
PITTSBURGH PA
15228-1629
US

V. Phone/Fax

Practice location:
  • Phone: 570-723-7764
  • Fax:
Mailing address:
  • Phone: 412-831-3744
  • Fax: 412-831-5663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: RONALD J BUTLER
Title or Position: PRESIDENT
Credential:
Phone: 570-723-7764