Basic Information
| Provider Information | |||||||||
| NPI: | 1215234976 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLINIC MEDICAL SERVICES COMPANY | ||||||||
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| OtherOrganizationName: | CLEVELAND CLINIC STAR IMAGING BOARDMAN-CANFIELD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6100 W CREEK RD STE 35 | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441312133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166428165 | ||||||||
| FaxNumber: | 2166421064 | ||||||||
| Practice Location | |||||||||
| Address1: | 1449 BOARDMAN CANFIELD RD STE 140 | ||||||||
| Address2: | |||||||||
| City: | BOARDMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445128070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309657370 | ||||||||
| FaxNumber: | 3309657377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2011 | ||||||||
| LastUpdateDate: | 02/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | KAFITI | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, BUSINESS OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2164455023 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLEVELAND CLINIC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.