Healthcare Provider Details

I. General information

NPI: 1255415063
Provider Name (Legal Business Name): GARY SISKIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 12/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALBANY MEDICAL CENTER HOSPITAL 47 NEW SCOTLAND AVE - RADIOLOGY
ALBANY NY
12208
US

IV. Provider business mailing address

711 TROY SCHENECTADY RD SUITE 201
LATHAM NY
12110-2442
US

V. Phone/Fax

Practice location:
  • Phone: 518-262-5149
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number188275
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number188275
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: