Basic Information
| Provider Information | |||||||||
| NPI: | 1225402779 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JCR MEDICINE CANAL STREET PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IMA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 248 | ||||||||
| Address2: | |||||||||
| City: | ELLICOTTVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147310248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154781977 | ||||||||
| FaxNumber: | 3154289223 | ||||||||
| Practice Location | |||||||||
| Address1: | 961 CANAL ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154781977 | ||||||||
| FaxNumber: | 3154289233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2015 | ||||||||
| LastUpdateDate: | 11/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | RADFORD | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7166999032 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.