Provider Demographics
NPI:1609941103
Name:SOUTHERN TIER OBSTETRICS & GYNECOLOGY PC
Entity Type:Organization
Organization Name:SOUTHERN TIER OBSTETRICS & GYNECOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:K
Authorized Official - Last Name:KWAKYE BERKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-372-2770
Mailing Address - Street 1:PO BOX 564
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760
Mailing Address - Country:US
Mailing Address - Phone:716-372-2770
Mailing Address - Fax:716-372-2740
Practice Address - Street 1:242 N UNION ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760
Practice Address - Country:US
Practice Address - Phone:716-372-2770
Practice Address - Fax:716-372-2740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2172551207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02107880Medicaid
NY02107880Medicaid
H00080Medicare UPIN