MEDICARE: HUDSON MOHAWK PEDIATRIC & ADOLESCENT MEDICINE

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	174400000X	Specialist	107075	NY

General Provider Information

NPI Number	:	1306950563
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUDSON MOHAWK PEDIATRIC & ADOLESCENT MEDICINE

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	:	518-899-5764

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	:	518-899-5764

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. GAYLE B BUCKLEY
Credential	:	M.D.
Telephone Number	:	518-899-4133

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	08/22/2020

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