Basic Information
| Provider Information | |||||||||
| NPI: | 1508100140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SCHENECTADY RADIOLOGISTS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 NOTT TERRACE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SCHENECTADY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183724405 | ||||||||
| FaxNumber: | 5183722272 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 SITTERLY ROAD | ||||||||
| Address2: | |||||||||
| City: | CLIFTON PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185792700 | ||||||||
| FaxNumber: | 5183722272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2012 | ||||||||
| LastUpdateDate: | 11/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | RADIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 5183724405 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 149212 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00752130 | 05 | NY | MEDICAID |