Basic Information
| Provider Information | |||||||||
| NPI: | 1053570747 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WADSWORTH IMAGING, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3090 W MARKET ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | FAIRLAWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443333608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308647109 | ||||||||
| FaxNumber: | 3308698910 | ||||||||
| Practice Location | |||||||||
| Address1: | 195 WADSWORTH RD | ||||||||
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| City: | WADSWORTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442819504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303341504 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2008 | ||||||||
| LastUpdateDate: | 06/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | CROCKER | ||||||||
| AuthorizedOfficialFirstName: | NORMAN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3308647109 | ||||||||
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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 MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.