Provider Demographics
NPI:1538113709
Name:GASTROENTEROLOGY ASSOCIATES OF ITHACA, PC
Entity Type:Organization
Organization Name:GASTROENTEROLOGY ASSOCIATES OF ITHACA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:T
Authorized Official - Last Name:BRENNAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-272-5011
Mailing Address - Street 1:2435 N TRIPHAMMER RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1047
Mailing Address - Country:US
Mailing Address - Phone:607-272-5011
Mailing Address - Fax:607-272-5861
Practice Address - Street 1:2435 N TRIPHAMMER RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1047
Practice Address - Country:US
Practice Address - Phone:607-272-5011
Practice Address - Fax:607-272-5861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02423352Medicaid
NY02423352Medicaid