Provider Demographics
NPI:1346531654
Name:SOUTHERN TIER UROLOGY CLINIC
Entity Type:Organization
Organization Name:SOUTHERN TIER UROLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:W
Authorized Official - Last Name:GIST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:202-636-1131
Mailing Address - Street 1:3359 LAURIE BROOK DR
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-3153
Mailing Address - Country:US
Mailing Address - Phone:202-636-1131
Mailing Address - Fax:
Practice Address - Street 1:3359 LAURIE BROOK DR
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-3153
Practice Address - Country:US
Practice Address - Phone:202-636-1131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234985208800000X, 2088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty