Provider Demographics
NPI:1528056942
Name:TRUMANSBURG MEDICINE PLLC
Entity type:Organization
Organization Name:TRUMANSBURG MEDICINE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:COOKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-387-5707
Mailing Address - Street 1:4435 SENECA RD
Mailing Address - Street 2:
Mailing Address - City:TRUMANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14886-9201
Mailing Address - Country:US
Mailing Address - Phone:607-387-5707
Mailing Address - Fax:607-387-4354
Practice Address - Street 1:4435 SENECA RD
Practice Address - Street 2:
Practice Address - City:TRUMANSBURG
Practice Address - State:NY
Practice Address - Zip Code:14886-9201
Practice Address - Country:US
Practice Address - Phone:607-387-5707
Practice Address - Fax:607-387-4354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02863638Medicaid
NY02863638Medicaid