Provider Demographics
NPI:1629069679
Name:GILL, TARIQ (MD)
Entity Type:Individual
Prefix:
First Name:TARIQ
Middle Name:
Last Name:GILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY-SCHENECTADY ROAD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:711 TROY-SCHENECTADY ROAD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110
Practice Address - Country:US
Practice Address - Phone:518-782-3700
Practice Address - Fax:518-782-3799
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1465012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00864902Medicaid
NY00864902Medicaid
CC2880Medicare ID - Type Unspecified
NYJ400078905Medicare PIN