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General NPI Number Information
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NPI Number | 1508241878
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Entity Type | Organization
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Legal Business Name | UPSTATE RADIOLOGY, PC
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Dates
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Enumeration Date | 07/28/2015
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Last Update Date | 07/28/2015
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Provider Practice Location Address
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Address Line | 1116 ARSENAL ST STE 504
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City | WATERTOWN
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State | NY
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Zip | 13601-2229
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Country | US
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Telephone | 315-782-2669
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Fax |
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Provider Business Mailing Address
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Address Line | 1116 ARSENAL ST STE 504
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City | WATERTOWN
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State | NY
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Zip | 13601-2229
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Country | US
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Telephone | 315-782-2669
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. GLAUCO MICHAEL MARESCA
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Credential | M.D.
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Telephone | 315-782-2669
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 177246
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License Number State | NY
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