Provider Demographics
NPI:1104837434
Name:BINGHAMTON PODIATRY PC
Entity Type:Organization
Organization Name:BINGHAMTON PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:WIXSOM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:607-724-1263
Mailing Address - Street 1:111 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:14903-1303
Mailing Address - Country:US
Mailing Address - Phone:607-734-9539
Mailing Address - Fax:607-734-6293
Practice Address - Street 1:38 FRONT ST
Practice Address - Street 2:# 2B
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4712
Practice Address - Country:US
Practice Address - Phone:607-724-1263
Practice Address - Fax:607-724-1263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00577151Medicaid
NYAA1589Medicare PIN
NY00577151Medicaid