Basic Information
| Provider Information | |||||||||
| NPI: | 1851324982 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANTASSEL | ||||||||
| FirstName: | PAMELA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23625 COMMERCE PARK | ||||||||
| Address2: | STE. 204 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162555700 | ||||||||
| FaxNumber: | 2162555701 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 N. NARBERTH AVENUE | ||||||||
| Address2: | |||||||||
| City: | NARBERTH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190721807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106677855 | ||||||||
| FaxNumber: | 8668982159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 11/23/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | MD071655L | PA | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | MD071655L | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 10807 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | G7364 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 108074 | 05 | SC | MEDICAID | 1851324982 | 05 | MI | MEDICAID | 8533119 | 05 | WA | MEDICAID | P00898180 | 01 | PA | RXR MEDICARE | OTHER | 1851324982 | 05 | IA | MEDICAID | 64601206 | 05 | KY | MEDICAID | 2916705 | 05 | OH | MEDICAID |