MEDICARE: MICHAEL DONALD RADOSEVICH M.D., P.H.D.

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	207W00000X	Ophthalmology Physician	36488	IA
2	207W00000X	Ophthalmology Physician	252133	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	19934	OTHER	IA	WELLMARK BCBS

General Provider Information

NPI Number	:	1932136827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL DONALD RADOSEVICH M.D., P.H.D.

Provider Business Mailing Address
First Line	:	5 MOUNTAIN LEDGE DR
Second Line	:
City	:	WILTON
State	:	NY
Zip	:	12831-2539
Country	:	US
Telephone Number	:	518-437-1111
Fax Number	:	518-435-1114

Provider Business Practice Location Address
First Line	:	1365 WASHINGTON AVE.
Second Line	:	SUITE 101
City	:	ALBANY
State	:	NY
Zip	:	12206-1099
Country	:	US
Telephone Number	:	518-437-1111
Fax Number	:	518-435-1114

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	10/01/2015

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