Basic Information
| Provider Information | |||||||||
| NPI: | 1477768174 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL MANAGEMENT SYSTEMS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3541 STIMSON RD | ||||||||
| Address2: | |||||||||
| City: | NORTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442036439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306773632 | ||||||||
| FaxNumber: | 3306778770 | ||||||||
| Practice Location | |||||||||
| Address1: | 1930 STATE ROUTE 59 | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306773632 | ||||||||
| FaxNumber: | 3306778770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 11/06/2007 | ||||||||
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| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | REBECCA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3306773632 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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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 | 2754783 | 05 | OH | MEDICAID |