Basic Information
| Provider Information | |||||||||
| NPI: | 1083798896 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CZAJKA | ||||||||
| FirstName: | ELLEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102442 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 711 TROY SCHENECTADY RD | ||||||||
| Address2: | SUITE 114 | ||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187861600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 12/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 146385 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00899445 | 05 | NY | MEDICAID |