Healthcare Provider Details

I. General information

NPI: 1427040781
Provider Name (Legal Business Name): MOHAWK GLEN IMAGING PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 PERIMETER RD
ROME NY
13441-4018
US

IV. Provider business mailing address

PO BOX 669
ROME NY
13442-0669
US

V. Phone/Fax

Practice location:
  • Phone: 315-334-9729
  • Fax:
Mailing address:
  • Phone: 315-339-7965
  • Fax: 315-709-0288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number153927
License Number StateNY

VIII. Authorized Official

Name: DR. LAWRENCE BURGREEN
Title or Position: DEPARTMENT HEAD
Credential: M.D.
Phone: 315-334-9729