Healthcare Provider Details

I. General information

NPI: 1124435607
Provider Name (Legal Business Name): RG SHERRY MD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 WASHINGTON ST
WATERTOWN NY
13601-4541
US

IV. Provider business mailing address

PO BOX 91
WATERTOWN NY
13601-0091
US

V. Phone/Fax

Practice location:
  • Phone: 540-597-2469
  • Fax:
Mailing address:
  • Phone: 315-782-4207
  • Fax: 315-782-8699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number126687-1
License Number StateNY

VIII. Authorized Official

Name: DR. RICHARD SHERRY
Title or Position: OWNER
Credential:
Phone: 540-597-8469