Provider Demographics
NPI:1912921263
Name:ITHACA ORTHOPAEDIC GROUP, PC
Entity Type:Organization
Organization Name:ITHACA ORTHOPAEDIC GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-266-0073
Mailing Address - Street 1:10 BRENTWOOD DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1865
Mailing Address - Country:US
Mailing Address - Phone:607-266-0073
Mailing Address - Fax:607-266-9310
Practice Address - Street 1:10 BRENTWOOD DR
Practice Address - Street 2:SUITE B
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1865
Practice Address - Country:US
Practice Address - Phone:607-266-0073
Practice Address - Fax:607-266-9310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY55136AMedicare ID - Type Unspecified
NY0931840001Medicare NSC