Provider Demographics
NPI:1548202971
Name:TIOGA HEALTH CARE PROVIDERS INC 4
Entity Type:Organization
Organization Name:TIOGA HEALTH CARE PROVIDERS INC 4
Other - Org Name:WELLSBORO ANESTHESIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-723-7764
Mailing Address - Street 1:1699 WASHINGTON RD
Mailing Address - Street 2:STE 307
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15228-1629
Mailing Address - Country:US
Mailing Address - Phone:412-831-3744
Mailing Address - Fax:412-831-5663
Practice Address - Street 1:32-36 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1840
Practice Address - Country:US
Practice Address - Phone:570-723-7764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAUAREL HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-11
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA046701Medicare ID - Type Unspecified