Provider Demographics
NPI:1619948288
Name:TIOGA HEALTHCARE PROVIDERS INC-6
Entity Type:Organization
Organization Name:TIOGA HEALTHCARE PROVIDERS INC-6
Other - Org Name:CANYON SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:570-723-0716
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-0191
Mailing Address - Country:US
Mailing Address - Phone:570-723-0716
Mailing Address - Fax:570-723-0638
Practice Address - Street 1:1 MAIN ST
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1601
Practice Address - Country:US
Practice Address - Phone:570-723-0716
Practice Address - Fax:570-723-0638
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAUREL HEALTH SYSTEMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-31
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1626712OtherHIGHMARK BLUE SHIELD
PADC0711OtherTRAVELERS MEDICARE
1626712OtherHIGHMARK BLUE SHIELD