Basic Information
| Provider Information | |||||||||
| NPI: | 1649274275 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERRIGAN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 LEROY ST | ||||||||
| Address2: | |||||||||
| City: | POTSDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136761786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152653300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 80 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136171450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152615870 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 17399 | MS | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 241293-1 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00124942 | 05 | MS | MEDICAID | BK6176487 | 01 | DEA | OTHER |