Provider Demographics
NPI:1710902200
Name:SOUTHERN TIER PEDIATRICS PRACTICE, P.C.
Entity Type:Organization
Organization Name:SOUTHERN TIER PEDIATRICS PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TARIQ
Authorized Official - Middle Name:M
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-661-9730
Mailing Address - Street 1:1684 FOOTE AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-9385
Mailing Address - Country:US
Mailing Address - Phone:716-661-9730
Mailing Address - Fax:716-661-9732
Practice Address - Street 1:1684 FOOTE AVENUE EXT
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-9385
Practice Address - Country:US
Practice Address - Phone:716-661-9730
Practice Address - Fax:716-661-9732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2074692080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02690682Medicaid
NY01664951Medicaid
NY=========OtherFEDERAL TAX ID