Basic Information
| Provider Information | |||||||||
| NPI: | 1720075799 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEAGHER | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | DECLAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 S MAIN ST STE 250 | ||||||||
| Address2: | P O BOX 788 | ||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147016627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166649731 | ||||||||
| FaxNumber: | 7166649160 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 FOOTE AVE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147017077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164210141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 12/12/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 199207 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1992072WDRDRA | 01 | NY | WORKERS COMPENSATION | OTHER | 01568143 | 05 | NY | MEDICAID |