Provider Demographics
NPI:1114933934
Name:ADIRONDACK DIAGNOSTIC IMAGING OF QUEENSBURY
Entity Type:Organization
Organization Name:ADIRONDACK DIAGNOSTIC IMAGING OF QUEENSBURY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-373-2121
Mailing Address - Street 1:632 PLANK RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-2019
Mailing Address - Country:US
Mailing Address - Phone:518-373-2121
Mailing Address - Fax:518-373-1762
Practice Address - Street 1:375 BAY RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-3012
Practice Address - Country:US
Practice Address - Phone:518-792-1700
Practice Address - Fax:518-792-1711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
RA0369Medicare ID - Type Unspecified