Basic Information
| Provider Information | |||||||||
| NPI: | 1669408332 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALBANY MEDICAL CENTER SOUTH CLINICAL CAMPUS | ||||||||
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| OtherOrganizationName: | SCC DEPT OF RADIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 618 CENTRAL AVE | ||||||||
| Address2: | MAIL CODE 106 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122061916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182629702 | ||||||||
| FaxNumber: | 5182629707 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 HACKETT BLVD | ||||||||
| Address2: | MAIL CODE 113 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122083420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182628481 | ||||||||
| FaxNumber: | 5182628146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FRISCH | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF HOSPITAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5182623028 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0203X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0204X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0205X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiological Physics | 2085U0001X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 02333535 | 05 | NY | MEDICAID | 01520676 | 05 | NY | MEDICAID | 1012836 | 05 | VT | MEDICAID |