Provider Demographics
NPI:1346346202
Name:SPECTRUM RADIOLOGY ASSOCIATES PLLC
Entity type:Organization
Organization Name:SPECTRUM RADIOLOGY ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON-GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-688-7622
Mailing Address - Street 1:1150 YOUNGS RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8053
Mailing Address - Country:US
Mailing Address - Phone:716-688-7622
Mailing Address - Fax:716-688-7592
Practice Address - Street 1:1150 YOUNGS RD
Practice Address - Street 2:SUITE 111
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8053
Practice Address - Country:US
Practice Address - Phone:716-688-7622
Practice Address - Fax:716-688-7592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02143864Medicaid
NY512627001OtherBLUE CROOS WNY GROUP NO.
NY512627001OtherBLUE CROOS WNY GROUP NO.
NYAA0752Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER