Basic Information
| Provider Information | |||||||||
| NPI: | 1639364334 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RAMIC BOARDMAN, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1449 BOARDMAN CANFIELD RD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | BOARDMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445128061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309657370 | ||||||||
| FaxNumber: | 3309657377 | ||||||||
| Practice Location | |||||||||
| Address1: | 1449 BOARDMAN CANFIELD RD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | BOARDMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445128061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309657370 | ||||||||
| FaxNumber: | 3309657377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2007 | ||||||||
| LastUpdateDate: | 01/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | SHAWN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3304954821 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AIMI IMAGING SERVICES, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 0838IC | OH | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 2938030 | 05 | OH | MEDICAID |