Basic Information
Provider Information | |||||||||
NPI: | 1669431441 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH COUNTRY PRECISION MEDICAL IMAGING, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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Mailing Information | |||||||||
Address1: | 1116 ARSENAL ST | ||||||||
Address2: | SUITE 504 | ||||||||
City: | WATERTOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 136012229 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157822620 | ||||||||
FaxNumber: | 3157884980 | ||||||||
Practice Location | |||||||||
Address1: | ALICE HYDE HOSPITAL | ||||||||
Address2: | 133 PARK ST | ||||||||
City: | MALONE | ||||||||
State: | NY | ||||||||
PostalCode: | 12953 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157822620 | ||||||||
FaxNumber: | 3157884980 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CRUMP | ||||||||
AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | HIPAA COMPLIANCE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 3157822620 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
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AuthorizedOfficialCredential: | CCSP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.