Basic Information
| Provider Information | |||||||||
| NPI: | 1588661904 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPONOVO | ||||||||
| FirstName: | ERNEST | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3700 PARK EAST DRIVE | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552921401 | ||||||||
| FaxNumber: | 8663938340 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 PARK EAST DRIVE | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552921401 | ||||||||
| FaxNumber: | 8663938340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 05/26/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD042369L | PA | N | Other Service Providers | Specialist | 2085R0202X | MD042369L | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 003566900 | 05 | FL | MEDICAID | 0012389070048 | 05 | PA | MEDICAID | 7100356790 | 05 | KY | MEDICAID | 057342600 | 05 | DC | MEDICAID | 1588661904 | 05 | CA | MEDICAID | 1588661904 | 05 | MI | MEDICAID | 470001500 | 05 | MD | MEDICAID |