MEDICARE: HUDSON MOHAWK PEDIATRICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282NC2000X	Children's Hospital	107075	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225393986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUDSON MOHAWK PEDIATRICS

Provider Business Mailing Address
First Line	:	318 RUHLE RD S
Second Line	:
City	:	BALLSTON LAKE
State	:	NY
Zip	:	12019-1030
Country	:	US
Telephone Number	:	518-899-4133
Fax Number	:

Provider Business Practice Location Address
First Line	:	318 RUHLE RD S
Second Line	:
City	:	BALLSTON LAKE
State	:	NY
Zip	:	12019-1030
Country	:	US
Telephone Number	:	518-899-4133
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GAYLE BUCKLEY
Credential	:
Telephone Number	:	518-899-4133

Provider Enumeration Date	:	07/09/2012
Last Update Date	:	07/09/2012

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