Basic Information
| Provider Information | |||||||||
| NPI: | 1720031446 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMUNDSON | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 E ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132102342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3164647433 | ||||||||
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| Practice Location | |||||||||
| Address1: | 750 E ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132102342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154647433 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 01/24/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085P0229X | MD420848 | PA | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | 46808-020 | WI | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | 21983 | NE | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | 42387 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | 4301053830 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | 35.043846 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | 28490 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | MD00047561 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | 41082 | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
| ID | Type | State | Issuer | Description | 64037203 | 01 | KY | MEDICAID | OTHER | 000000565302 | 01 | KY | ANTHEM/NORTON | OTHER | 00533040 | 01 | KY | MEDICARE | OTHER | 3525222000 | 01 | PASSPORT ADVANTAGE | OTHER | 50019410 | 01 | PASSPORT | OTHER | 096386 | 01 | SIHO | OTHER | 200331670 | 05 | IN | MEDICAID | 0000230324 | 01 | KY | HUMANA | OTHER |