Provider Demographics
NPI:1417050881
Name:ARCHAMBAULT, MAUREEN KEOGH (MD)
Entity Type:Individual
Prefix:DR
First Name:MAUREEN
Middle Name:KEOGH
Last Name:ARCHAMBAULT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:MAUREEN
Other - Middle Name:ARCHAMBAULT
Other - Last Name:UERSACI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2528 PETERS LANE
Mailing Address - Street 2:
Mailing Address - City:NISKEYUNA
Mailing Address - State:NY
Mailing Address - Zip Code:12309-2413
Mailing Address - Country:US
Mailing Address - Phone:518-370-1455
Mailing Address - Fax:518-370-2093
Practice Address - Street 1:2528 PETERS LANE
Practice Address - Street 2:
Practice Address - City:NISKEYUNA
Practice Address - State:NY
Practice Address - Zip Code:12309-2413
Practice Address - Country:US
Practice Address - Phone:518-370-1455
Practice Address - Fax:518-370-2093
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1071492085R0001X
NM200203722085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY810320Medicaid
NY810320Medicaid
NY551353CMedicare ID - Type Unspecified