Provider Demographics
NPI:1538466115
Name:MOHAWK GLEN RADIOLOGY ASSOCIATES OF CNY PLLC
Entity Type:Organization
Organization Name:MOHAWK GLEN RADIOLOGY ASSOCIATES OF CNY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED SIGNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:J
Authorized Official - Last Name:FRACCOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-382-3031
Mailing Address - Street 1:PO BOX 394
Mailing Address - Street 2:
Mailing Address - City:CANAJOHARIE
Mailing Address - State:NY
Mailing Address - Zip Code:13317-0394
Mailing Address - Country:US
Mailing Address - Phone:315-339-7965
Mailing Address - Fax:814-235-1566
Practice Address - Street 1:91 PERIMETER RD
Practice Address - Street 2:SUITE 110
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:315-334-1185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-17
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03387708Medicaid