MEDICARE: OTTER CREEK MEDICAL OFFICE, LLP

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	208000000X	Pediatrics Physician	187190	NY
2	207Q00000X	Family Medicine Physician	000148	NY
3	207Q00000X	Family Medicine Physician	186955	NY

General Provider Information

NPI Number	:	1164478293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OTTER CREEK MEDICAL OFFICE, LLP

Provider Business Mailing Address
First Line	:	2 ELM ST
Second Line	:
City	:	MC GRAW
State	:	NY
Zip	:	13101-9471
Country	:	US
Telephone Number	:	607-836-7540
Fax Number	:	607-836-4180

Provider Business Practice Location Address
First Line	:	2 ELM ST
Second Line	:
City	:	MC GRAW
State	:	NY
Zip	:	13101-9471
Country	:	US
Telephone Number	:	607-836-7540
Fax Number	:	607-836-4180

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. MARY THERESE MASTRUCCI
Credential	:	M.D.
Telephone Number	:	607-756-0709

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	11/03/2008

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