MEDICARE: MOHAWK VALLEY OPEN MRI, PC

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	2085R0202X	Diagnostic Radiology Physician	153927	NY

General Provider Information

NPI Number	:	1326031725
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOHAWK VALLEY OPEN MRI, PC

Provider Business Mailing Address
First Line	:	PO BOX 669
Second Line	:
City	:	ROME
State	:	NY
Zip	:	13442-0669
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1819 BLACK RIVER BLVD N
Second Line	:
City	:	ROME
State	:	NY
Zip	:	13440-2427
Country	:	US
Telephone Number	:	315-339-2671
Fax Number	:

Authorized Official
Title or Position	:	DEPARTMENT HEAD
Name	:	DR. LAWRENCE BURGREEN
Credential	:	M.D.
Telephone Number	:	315-339-2671

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	09/12/2007

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