Provider Demographics
NPI:1184634297
Name:MONDRAGON MCGRINDER MEDICAL ASSOCIATES PLLC
Entity Type:Organization
Organization Name:MONDRAGON MCGRINDER MEDICAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAROLA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:518-374-9153
Mailing Address - Street 1:700 MCCLELLAN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12304-1019
Mailing Address - Country:US
Mailing Address - Phone:518-374-9153
Mailing Address - Fax:518-379-5195
Practice Address - Street 1:700 MCCLELLAN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12304-1019
Practice Address - Country:US
Practice Address - Phone:518-374-9153
Practice Address - Fax:518-379-5195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02116829Medicaid
NYCJ6592Medicare PIN