Provider Demographics
NPI:1598794885
Name:SOUTHERN TIER PEDIATRICS PC
Entity Type:Organization
Organization Name:SOUTHERN TIER PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-734-2264
Mailing Address - Street 1:3344 CHAMBERS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-1403
Mailing Address - Country:US
Mailing Address - Phone:607-734-2264
Mailing Address - Fax:607-767-0340
Practice Address - Street 1:3344 CHAMBERS RD STE 200
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-1403
Practice Address - Country:US
Practice Address - Phone:607-734-2264
Practice Address - Fax:607-767-0340
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN TIER PEDIATRICS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
53030AMedicare ID - Type Unspecified
NY00932641Medicare ID - Type Unspecified