Provider Demographics
NPI:1588967483
Name:ADIRONDACK ADVANCE IMAGING LLC
Entity type:Organization
Organization Name:ADIRONDACK ADVANCE IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOYAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-409-8811
Mailing Address - Street 1:375 BAY RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-3012
Mailing Address - Country:US
Mailing Address - Phone:518-409-8811
Mailing Address - Fax:518-409-8814
Practice Address - Street 1:375 BAY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-3012
Practice Address - Country:US
Practice Address - Phone:518-409-8811
Practice Address - Fax:518-409-8814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-15
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ100071387Medicare PIN