Provider Demographics
NPI:1760821417
Name:CANTON-POTSDAM MEDICAL PRACTICE PLLC
Entity Type:Organization
Organization Name:CANTON-POTSDAM MEDICAL PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:315-261-6013
Mailing Address - Street 1:50 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676
Mailing Address - Country:US
Mailing Address - Phone:315-265-3300
Mailing Address - Fax:315-261-6025
Practice Address - Street 1:80 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617
Practice Address - Country:US
Practice Address - Phone:315-265-3300
Practice Address - Fax:315-261-6025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-17
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ100093911OtherPTAN
NY03652971Medicaid