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General NPI Number Information
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NPI Number | 1346531654
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Entity Type | Organization
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Legal Business Name | SOUTHERN TIER UROLOGY CLINIC
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Dates
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Enumeration Date | 04/21/2011
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Last Update Date | 04/21/2011
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Provider Practice Location Address
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Address Line | 3359 LAURIE BROOK DR
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City | BINGHAMTON
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State | NY
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Zip | 13903-3153
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Country | US
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Telephone | 202-636-1131
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Fax |
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Provider Business Mailing Address
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Address Line | 3359 LAURIE BROOK DR
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City | BINGHAMTON
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State | NY
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Zip | 13903-3153
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Country | US
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Telephone | 202-636-1131
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. CHRISTOPHER W GIST
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Credential | MD
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Telephone | 202-636-1131
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2088P0231X
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Taxonomy Name | Pediatric Urology Physician
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License Number | 234985
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 234985
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License Number State | NY
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