Provider Demographics
NPI:1861551822
Name:ST LAWRENCE COUNTY
Entity type:Organization
Organization Name:ST LAWRENCE COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FISCAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:315-229-3405
Mailing Address - Street 1:80 STATE HIGHWAY 310 STE 2
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1476
Mailing Address - Country:US
Mailing Address - Phone:315-386-2325
Mailing Address - Fax:315-386-2203
Practice Address - Street 1:80 STATE HIGHWAY 310 STE 2
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1476
Practice Address - Country:US
Practice Address - Phone:315-386-2325
Practice Address - Fax:315-386-2203
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST LAWRENCE COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-06
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
NY4423200R261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04006057Medicaid
NY04006057Medicaid
NY00583679Medicaid
NY00591391Medicaid
NYJ300052898Medicare PIN
NY00976009Medicaid