1760821417 NPI number — CANTON-POTSDAM MEDICAL PRACTICE PLLC

Table of content: (NPI 1760821417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760821417 NPI number — CANTON-POTSDAM MEDICAL PRACTICE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANTON-POTSDAM MEDICAL PRACTICE PLLC
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:
1760821417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 LEROY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POTSDAM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13676
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-265-3300
Provider Business Mailing Address Fax Number:
315-261-6025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 EAST MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-265-3300
Provider Business Practice Location Address Fax Number:
315-261-6025
Provider Enumeration Date:
06/17/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PEGGS
Authorized Official First Name:
ASHLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER ENROLLMENT MANAGER
Authorized Official Telephone Number:
315-261-5044

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: J100093911 . This is a "PTAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 03652971 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com