Basic Information
| Provider Information | |||||||||
| NPI: | 1154380863 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LAWRENCE RADIOLOGY ASSOC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 41643 | ||||||||
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| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212036643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432742888 | ||||||||
| FaxNumber: | 4432742391 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 LEROY ST | ||||||||
| Address2: | CANTON POTSDAM HOSPITAL | ||||||||
| City: | POTSDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136761786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157822620 | ||||||||
| FaxNumber: | 3157884980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 06/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | MARESCA | ||||||||
| AuthorizedOfficialFirstName: | GLAUCO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3152654924 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 01350563 | 05 | NY | MEDICAID |