Basic Information
| Provider Information | |||||||||
| NPI: | 1831282185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S JULIANA ST | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 155221736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8146237279 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 411 OAK ST | ||||||||
| Address2: | STERLING MEDICAL ASSOCIATES | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139841800 | ||||||||
| FaxNumber: | 5139844909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD026205E | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | D795479 | 05 | PA | MEDICAID |