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General NPI Number Information
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NPI Number | 1760821417
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Entity Type | Organization
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Legal Business Name | CANTON-POTSDAM MEDICAL PRACTICE PLLC
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Dates
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Enumeration Date | 06/17/2013
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Last Update Date | 11/13/2024
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Provider Practice Location Address
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Address Line | 80 EAST MAIN STREET
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City | CANTON
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State | NY
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Zip | 13617
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Country | US
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Telephone | 315-265-3300
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Fax | 315-261-6025
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Provider Business Mailing Address
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Address Line | 50 LEROY ST
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City | POTSDAM
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State | NY
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Zip | 13676
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Country | US
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Telephone | 315-265-3300
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Fax | 315-261-6025
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Authorized Official
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Title or Position | PROVIDER ENROLLMENT MANAGER
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Name | ASHLEY PEGGS
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Credential |
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Telephone | 315-261-5044
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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