Provider Demographics
NPI:1063253482
Name:LAKE CHAMPLAIN IMAGING PLLC
Entity type:Organization
Organization Name:LAKE CHAMPLAIN IMAGING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:G
Authorized Official - Last Name:CONTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-572-6333
Mailing Address - Street 1:10 SPIT FIRE DR
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-8521
Mailing Address - Country:US
Mailing Address - Phone:518-572-6333
Mailing Address - Fax:
Practice Address - Street 1:675 STATE ROUTE 3
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-6562
Practice Address - Country:US
Practice Address - Phone:518-572-6333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty