Provider Demographics
NPI:1396763124
Name:IVY OBSTETRICS & GYNECOLOGY ASSOC PC
Entity type:Organization
Organization Name:IVY OBSTETRICS & GYNECOLOGY ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-734-4191
Mailing Address - Street 1:600 IVY ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-1627
Mailing Address - Country:US
Mailing Address - Phone:607-734-4191
Mailing Address - Fax:607-734-0026
Practice Address - Street 1:600 IVY ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1627
Practice Address - Country:US
Practice Address - Phone:607-734-4191
Practice Address - Fax:607-734-0026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01345431Medicaid
NY34684AMedicare PIN