Basic Information
| Provider Information | |||||||||
| NPI: | 1316999121 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RADIOLOGY AND IMAGING SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUMMIT VASCULAR SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 931286 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441931494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887199012 | ||||||||
| FaxNumber: | 3304937123 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 WABASH AVE | ||||||||
| Address2: | SUITE 3500 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443072433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303441400 | ||||||||
| FaxNumber: | 3303440112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 02/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | MCBRIDE | ||||||||
| AuthorizedOfficialFirstName: | CARRIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3303441400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RADIOLOGY AND IMAGING SERVICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | CC3678 | 01 | OH | RAILROAD MEDICARE GROUP | OTHER | 2622139 | 05 | OH | MEDICAID |