MEDICARE: GASTROENTEROLOGY ASSOCIATES OF THE SOUTHERN TIER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CN0726	OTHER	NY	RAILROAD MEDICARE GROUP #

General Provider Information

NPI Number	:	1134226491
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GASTROENTEROLOGY ASSOCIATES OF THE SOUTHERN TIER

Provider Business Mailing Address
First Line	:	378 W CHURCH ST
Second Line	:
City	:	ELMIRA
State	:	NY
Zip	:	14901-2621
Country	:	US
Telephone Number	:	607-734-7121
Fax Number	:	607-734-0614

Provider Business Practice Location Address
First Line	:	378 W CHURCH ST
Second Line	:
City	:	ELMIRA
State	:	NY
Zip	:	14901-2621
Country	:	US
Telephone Number	:	607-734-7121
Fax Number	:	607-734-0614

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. BRUNO ROBERT MAZZA
Credential	:	MD
Telephone Number	:	607-734-7121

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	04/10/2008

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