Basic Information
| Provider Information | |||||||||
| NPI: | 1659539344 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLINIC MEDICAL SERVICES COMPANY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLEVELAND CLINIC STAR IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6100 W CREEK RD | ||||||||
| Address2: | SUITE 35 | ||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441312133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166428165 | ||||||||
| FaxNumber: | 2166421064 | ||||||||
| Practice Location | |||||||||
| Address1: | 7067 TIFFANY BLVD | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445141993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307582528 | ||||||||
| FaxNumber: | 3307582821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2008 | ||||||||
| LastUpdateDate: | 05/29/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAIORANA | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGED CARE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2166428165 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLEVELAND CLINC FOUNDATION | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 1228IC | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.