MEDICARE: CLAY CT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1790953891
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLAY CT, LLC

Provider Business Mailing Address
First Line	:	PO BOX 2004
Second Line	:
City	:	EAST SYRACUSE
State	:	NY
Zip	:	13057-4504
Country	:	US
Telephone Number	:	315-362-5285
Fax Number	:	315-445-2936

Provider Business Practice Location Address
First Line	:	8395 OSWEGO RD
Second Line	:
City	:	BALDWINSVILLE
State	:	NY
Zip	:	13027-6801
Country	:	US
Telephone Number	:	315-857-0094
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JOHN SHARP
Credential	:
Telephone Number	:	315-857-0094

Provider Enumeration Date	:	02/12/2008
Last Update Date	:	02/12/2008

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