Provider Demographics
NPI:1154380863
Name:ST LAWRENCE RADIOLOGY ASSOC PC
Entity type:Organization
Organization Name:ST LAWRENCE RADIOLOGY ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLAUCO
Authorized Official - Middle Name:
Authorized Official - Last Name:MARESCA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-265-4924
Mailing Address - Street 1:PO BOX 41643
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21203-6643
Mailing Address - Country:US
Mailing Address - Phone:443-274-2888
Mailing Address - Fax:443-274-2391
Practice Address - Street 1:50 LEROY ST
Practice Address - Street 2:CANTON POTSDAM HOSPITAL
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1786
Practice Address - Country:US
Practice Address - Phone:315-782-2620
Practice Address - Fax:315-788-4980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01350563Medicaid