Provider Demographics
NPI:1720031446
Name:AMUNDSON, GARY M (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:AMUNDSON
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 1:750 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2342
Mailing Address - Country:US
Mailing Address - Phone:316-464-7433
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2342
Practice Address - Country:US
Practice Address - Phone:315-464-7433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4208482085P0229X
WI46808-0202085P0229X
NE219832085P0229X
MN423872085P0229X
MI43010538302085P0229X
OH35.0438462085P0229X
SC284902085P0229X
WAMD000475612085P0229X
KY410822085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64037203OtherMEDICAID
KY000000565302OtherANTHEM/NORTON
KY00533040OtherMEDICARE
3525222000OtherPASSPORT ADVANTAGE
50019410OtherPASSPORT
096386OtherSIHO
IN200331670Medicaid
KY0000230324OtherHUMANA