Provider Demographics
NPI:1679526669
Name:CHRISTIAN D. TVETENSTRAND MD, PLLC
Entity Type:Organization
Organization Name:CHRISTIAN D. TVETENSTRAND MD, PLLC
Other - Org Name:SOUTHERN TIER SURGICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:DAHN
Authorized Official - Last Name:TVETENSTRAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-763-8205
Mailing Address - Street 1:30 HARRISON ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2161
Mailing Address - Country:US
Mailing Address - Phone:607-763-8205
Mailing Address - Fax:607-763-8208
Practice Address - Street 1:30 HARRISON ST
Practice Address - Street 2:SUITE 320
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2161
Practice Address - Country:US
Practice Address - Phone:607-763-8205
Practice Address - Fax:607-763-8208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178438174400000X
NY011154363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01135079Medicaid
NYBA0621Medicare PIN
E15648Medicare UPIN