Basic Information
Provider Information | |||||||||
NPI: | 1760821417 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CANTON-POTSDAM MEDICAL PRACTICE PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 50 LEROY ST | ||||||||
Address2: |   | ||||||||
City: | POTSDAM | ||||||||
State: | NY | ||||||||
PostalCode: | 13676 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3152653300 | ||||||||
FaxNumber: | 3152616025 | ||||||||
Practice Location | |||||||||
Address1: | 80 EAST MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | NY | ||||||||
PostalCode: | 13617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3152653300 | ||||||||
FaxNumber: | 3152616025 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2013 | ||||||||
LastUpdateDate: | 05/02/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROGERS | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 3152616013 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | II | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | J100093911 | 01 | NY | PTAN | OTHER | 03652971 | 05 | NY |   | MEDICAID |