Basic Information
| Provider Information | |||||||||
| NPI: | 1417970542 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | X-RAY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 967 BELLEFONTAINE AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192256346 | ||||||||
| FaxNumber: | 4192256609 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 BELLEFONTAINE AVE | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192265055 | ||||||||
| FaxNumber: | 4192265064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GORDON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4193036805 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000024953 | 01 | OH | ANTHEM | OTHER | 0517686 | 05 | OH | MEDICAID | 2212411 | 05 | OH | MEDICAID | CF7375 | 01 | RAILROAD MEDICARE | OTHER |