1154380863 NPI number — ST LAWRENCE RADIOLOGY ASSOC PC

Table of content: (NPI 1154380863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154380863 NPI number — ST LAWRENCE RADIOLOGY ASSOC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST LAWRENCE RADIOLOGY ASSOC PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154380863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 41643
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21203-6643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-274-2888
Provider Business Mailing Address Fax Number:
443-274-2391

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 LEROY ST
Provider Second Line Business Practice Location Address:
CANTON POTSDAM HOSPITAL
Provider Business Practice Location Address City Name:
POTSDAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13676-1786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-782-2620
Provider Business Practice Location Address Fax Number:
315-788-4980
Provider Enumeration Date:
03/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARESCA
Authorized Official First Name:
GLAUCO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
315-265-4924

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01350563 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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