=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437190162
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN TIER PLASTIC SURGERY ASSOCIATES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2006
-----------------------------------------------------
Last Update Date | 06/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 445 E WATER ST
-----------------------------------------------------
City | ELMIRA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14901-3410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-734-2067
-----------------------------------------------------
Fax | 607-732-1349
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 445 E WATER ST
-----------------------------------------------------
City | ELMIRA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14901-3410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-734-2067
-----------------------------------------------------
Fax | 607-732-1349
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARK S ANTHONY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 607-734-2067
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 201319
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 2323781
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 1857511
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------