Basic Information
| Provider Information | |||||||||
| NPI: | 1366513830 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENN IMAGING ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1675 E MAIN ST | ||||||||
| Address2: | BOX 328 | ||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442405818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306773632 | ||||||||
| FaxNumber: | 3306778770 | ||||||||
| Practice Location | |||||||||
| Address1: | 1930 STATE ROUTE 59 | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442404112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7246564127 | ||||||||
| FaxNumber: | 7246564165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 11/06/2007 | ||||||||
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| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | ALBERT | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3306773632 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1018351230001 | 05 | PA | MEDICAID | 27301383 | 05 | OH | MEDICAID |