Basic Information
| Provider Information | |||||||||
| NPI: | 1871552554 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORTLAND MEMORIAL RADIOLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1116 ARSENAL ST | ||||||||
| Address2: | SUITE 504 | ||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136016120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157822620 | ||||||||
| FaxNumber: | 3157884980 | ||||||||
| Practice Location | |||||||||
| Address1: | 134 HOMER AVE | ||||||||
| Address2: | CORTLAND REGIONAL MEDICAL CENTER | ||||||||
| City: | CORTLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130450960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157822620 | ||||||||
| FaxNumber: | 3157884980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 09/06/2007 | ||||||||
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| AuthorizedOfficialLastName: | CRUMP | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | HIPAA COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3157822620 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CCSP | ||||||||
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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.