NPIMap

Organization Active NPI

Southern Tier Pediatrics Practice, P.C.

  • Pediatric Adolescent Medicine Physician
  • Jamestown, NY
National Provider Identifier
1710902200
Registry record updated May 15, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric Adolescent Medicine PhysicianTaxonomy code 2080A0000X
License
207469 Issued in NY
Legal business name
SOUTHERN TIER PEDIATRICS PRACTICE, P.C.
Practice address
1684 Foote Avenue Ext
Jamestown, NY 14701-9385
Phone
(716) 661-9730
Fax
(716) 661-9732
NPI assigned
Jul 13, 2006
Last updated
May 15, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 15, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tariq M Khan, M.D.NPI 1922002906
Title
President
Phone
(716) 661-9730

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Adolescent Medicine Physician 2080A0000X 207469 NY Primary

Addresses

Primary practice location

1684 Foote Avenue Ext
Jamestown, NY 14701-9385

Mailing address

1684 Foote Avenue Ext
Jamestown, NY 14701-9385
Phone (716) 661-9730

Other identifiers 2

IdentifierTypeStateIssuer
02690682MedicaidNY
01664951MedicaidNY

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
33D0972508Southern Tier Pediatrics Practice PC1684 Foote Avenue Extension, Jamestown, NY 14701Certificate of waiverApr 9, 2028

National Provider Directory

National Provider Directory

Locations

1684 Foote Avenue Ext
Jamestown, NY 14701
Phone (716) 661-9730

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152748800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1368576000000",
    "number": "1710902200",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1684 FOOTE AVENUE EXT",
            "city": "JAMESTOWN",
            "state": "NY",
            "postal_code": "147019385",
            "telephone_number": "716-661-9730",
            "fax_number": "716-661-9732"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1684 FOOTE AVENUE EXT",
            "city": "JAMESTOWN",
            "state": "NY",
            "postal_code": "147019385",
            "telephone_number": "716-661-9730",
            "fax_number": "716-661-9732"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN TIER PEDIATRICS PRACTICE, P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-13",
        "last_updated": "2013-05-15",
        "status": "A",
        "authorized_official_last_name": "KHAN",
        "authorized_official_first_name": "TARIQ",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "716-661-9730",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "2080A0000X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Adolescent Medicine",
            "state": "NY",
            "license": "207469",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "02690682",
            "state": "NY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01664951",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Jamestown, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 15, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.