Provider Demographics
NPI:1427040781
Name:MOHAWK GLEN IMAGING PC
Entity Type:Organization
Organization Name:MOHAWK GLEN IMAGING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT HEAD
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-334-9729
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13442-0669
Mailing Address - Country:US
Mailing Address - Phone:315-339-7965
Mailing Address - Fax:315-709-0288
Practice Address - Street 1:91 PERIMETER RD
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13441-4018
Practice Address - Country:US
Practice Address - Phone:315-334-9729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1539272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty