Basic Information
| Provider Information | |||||||||
| NPI: | 1073512174 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAHONING VALLEY IMAGING LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 182255 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432182255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144305730 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7067 TIFFANY BLVD | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445141993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306292366 | ||||||||
| FaxNumber: | 3306292634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | BALL | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3306292366 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 34005921 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2102861 | 05 | OH | MEDICAID |