Healthcare Provider Details

I. General information

NPI: 1053370742
Provider Name (Legal Business Name): GLAUCO MICHAEL MARESCA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 LEROY ST CANTON-POTSDAM HOSPITAL
POTSDAM NY
13676-1786
US

IV. Provider business mailing address

PO BOX 41643
BALTIMORE MD
21203-6643
US

V. Phone/Fax

Practice location:
  • Phone: 315-265-4924
  • Fax: 315-268-1723
Mailing address:
  • Phone: 315-265-4924
  • Fax: 315-268-1723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number177246-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number177246
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: