Provider Demographics
NPI:1952469769
Name:SOUTHERN TIER ONCOLOGY LLC
Entity Type:Organization
Organization Name:SOUTHERN TIER ONCOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PRADEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-324-0061
Mailing Address - Street 1:21 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:HORNELL
Mailing Address - State:NY
Mailing Address - Zip Code:14843-2111
Mailing Address - Country:US
Mailing Address - Phone:607-324-0061
Mailing Address - Fax:607-324-7547
Practice Address - Street 1:21 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:HORNELL
Practice Address - State:NY
Practice Address - Zip Code:14843-2111
Practice Address - Country:US
Practice Address - Phone:607-324-0061
Practice Address - Fax:607-324-7547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203350174400000X
NY203720174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01732576Medicaid
NY01678477Medicaid
NYAA0728Medicare ID - Type Unspecified
NY01678477Medicaid
NY01732576Medicaid
NY4617000001Medicare NSC