Basic Information
Provider Information | |||||||||
NPI: | 1740464643 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AUBURN RADIOLOGY PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1116 ARSENAL ST STE 504 | ||||||||
Address2: | PO BOX 6120 | ||||||||
City: | WATERTOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 136012229 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157822620 | ||||||||
FaxNumber: | 3157884980 | ||||||||
Practice Location | |||||||||
Address1: | 17 LANSING ST | ||||||||
Address2: | AUBURN MEMORIAL HOSPITAL | ||||||||
City: | AUBURN | ||||||||
State: | NY | ||||||||
PostalCode: | 13021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157822620 | ||||||||
FaxNumber: | 3157884980 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2007 | ||||||||
LastUpdateDate: | 05/19/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARESCA | ||||||||
AuthorizedOfficialFirstName: | G | ||||||||
AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3157822620 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.