Basic Information
| Provider Information | |||||||||
| NPI: | 1447332762 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREYLOCK RADIOLOGY ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 291 MOODY ST | ||||||||
| Address2: | |||||||||
| City: | LUDLOW | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010561246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006886663 | ||||||||
| FaxNumber: | 4135897554 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH ADAMS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012472504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4136645279 | ||||||||
| FaxNumber: | 4135897554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 08/12/2014 | ||||||||
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| AuthorizedOfficialLastName: | BATH | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4136645279 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 9724818 | 05 | MA | MEDICAID | 102211300 | 01 | US DEPT OF LABOR | OTHER | 1000545 | 05 | VT | MEDICAID | 110068739/A | 05 | MA | MEDICAID | M13630 | 01 | MA | BC/BS | OTHER | 00743691 | 05 | NY | MEDICAID |