Basic Information
| Provider Information | |||||||||
| NPI: | 1821094178 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANCILLARY MEDICAL CONSULTANTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4197 FULTON DR NW | ||||||||
| Address2: | STE C | ||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447182819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304911490 | ||||||||
| FaxNumber: | 3304911466 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 S NAPPANEE ST | ||||||||
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| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465142066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742963200 | ||||||||
| FaxNumber: | 5742963936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | KIRK | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | ROB | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3304911490 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471C3401X | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Computed Tomography |
No ID Information.