Provider Demographics
NPI:1063851194
Name:TIOGA HEALTH CARE PROVIDERS, INC
Entity Type:Organization
Organization Name:TIOGA HEALTH CARE PROVIDERS, INC
Other - Org Name:SUSQUEHANNA HEALTH INTERNAL MEDICINE AT WELLSBORO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:GILBERT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:570-723-0600
Mailing Address - Street 1:22 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1526
Mailing Address - Country:US
Mailing Address - Phone:570-723-0600
Mailing Address - Fax:570-724-2126
Practice Address - Street 1:103 WEST AVE
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1358
Practice Address - Country:US
Practice Address - Phone:570-724-3744
Practice Address - Fax:570-724-2459
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUSQUEHANA HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-21
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
315280Medicare PIN