Basic Information
Provider Information | |||||||||
NPI: | 1184735854 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARLSON | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | ELLERT | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 23625 COMMERCE PARK | ||||||||
Address2: | SUITE 204 | ||||||||
City: | BEACHWOOD | ||||||||
State: | OH | ||||||||
PostalCode: | 441225845 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162555700 | ||||||||
FaxNumber: | 2162555701 | ||||||||
Practice Location | |||||||||
Address1: | 9764 COUNTRY CREEK WAY | ||||||||
Address2: |   | ||||||||
City: | DAYTON | ||||||||
State: | OH | ||||||||
PostalCode: | 454589242 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9378853954 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 07/07/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35068359 | OH | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 0460497 | 05 | OH |   | MEDICAID |