=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457440414
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. LAWRENCE PSYCHIATRIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 10/02/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 CHIMNEY POINT DR
-----------------------------------------------------
City | OGDENSBURG
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13669-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-541-2001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 CHIMNEY POINT DR
-----------------------------------------------------
City | OGDENSBURG
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13669-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRIST
-----------------------------------------------------
Name | KAMRUL A KHAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 267-266-6747
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------