Provider Demographics
NPI:1861469819
Name:HUTSAL, EDWIN P (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:P
Last Name:HUTSAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:14903-1318
Mailing Address - Country:US
Mailing Address - Phone:607-734-6237
Mailing Address - Fax:607-734-9728
Practice Address - Street 1:600 ROE AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1629
Practice Address - Country:US
Practice Address - Phone:607-734-3414
Practice Address - Fax:607-734-9728
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129259-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00360141Medicaid
NY35320EMedicare ID - Type Unspecified
NY00360141Medicaid