Provider Demographics
NPI:1265987325
Name:UPSTATE UNIVERSITY CLINICAL CAMPUS MEDICAL GROUP AT BINGHAMTON, INC.
Entity type:Organization
Organization Name:UPSTATE UNIVERSITY CLINICAL CAMPUS MEDICAL GROUP AT BINGHAMTON, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE PLAN MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LENORE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BORIS
Authorized Official - Suffix:
Authorized Official - Credentials:JD, PHD
Authorized Official - Phone:607-772-3516
Mailing Address - Street 1:425 ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13904-1735
Mailing Address - Country:US
Mailing Address - Phone:607-772-3516
Mailing Address - Fax:607-772-3536
Practice Address - Street 1:46 HARRISON ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2120
Practice Address - Country:US
Practice Address - Phone:607-729-6531
Practice Address - Fax:607-217-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty