Provider Demographics
NPI:1851762173
Name:OLIVE TREE MEDICAL ASSOCIATES PLLC
Entity Type:Organization
Organization Name:OLIVE TREE MEDICAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHASE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-269-4063
Mailing Address - Street 1:7505 FOOTE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323-3403
Mailing Address - Country:US
Mailing Address - Phone:315-269-4063
Mailing Address - Fax:315-338-5407
Practice Address - Street 1:7505 FOOTE RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-3403
Practice Address - Country:US
Practice Address - Phone:315-269-4063
Practice Address - Fax:315-338-5407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY253515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty