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1720055528

NPI Code Detail

MEDICARE: DR. THOMAS R. GUSTAFSON MD

MEDICARE: DR. THOMAS R. GUSTAFSON MD

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	207Q00000X	Family Medicine Physician	MD042588L	PA
2	207Q00000X	Family Medicine Physician	186217-1	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	080173355	OTHER	NY	RR MEDICARE PIN
4	CC8362	OTHER	NY	RR MEDICARE GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720055528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS R. GUSTAFSON MD

Provider Business Mailing Address
First Line	:	1 GUTHRIE SQ
Second Line	:
City	:	SAYRE
State	:	PA
Zip	:	18840-1625
Country	:	US
Telephone Number	:	570-888-5858
Fax Number	:

Provider Business Practice Location Address
First Line	:	1243 PENNSYLVANIA AVE
Second Line	:
City	:	PINE CITY
State	:	NY
Zip	:	14871-9230
Country	:	US
Telephone Number	:	607-734-3929
Fax Number	:	607-734-0781

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	07/29/2011

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Directions to “ DR. THOMAS R. GUSTAFSON MD” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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