Provider Demographics
NPI:1174945687
Name:SOUTHERN TIER MEDICAL PLLC
Entity type:Organization
Organization Name:SOUTHERN TIER MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BILLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARSTENS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:585-593-7246
Mailing Address - Street 1:243 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14895-1114
Mailing Address - Country:US
Mailing Address - Phone:585-593-7246
Mailing Address - Fax:
Practice Address - Street 1:243 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-1114
Practice Address - Country:US
Practice Address - Phone:585-593-7246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212342-12081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0600212342Medicaid
NY0600212342Medicaid