Provider Demographics
NPI:1023195088
Name:CINCINNATI PET SCAN, LLC
Entity Type:Organization
Organization Name:CINCINNATI PET SCAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-791-9959
Mailing Address - Street 1:651 CENTRE VIEW BLVD
Mailing Address - Street 2:110
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5423
Mailing Address - Country:US
Mailing Address - Phone:859-547-1240
Mailing Address - Fax:859-547-1245
Practice Address - Street 1:651 CENTRE VIEW BLVD
Practice Address - Street 2:110
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-5423
Practice Address - Country:US
Practice Address - Phone:859-547-1240
Practice Address - Fax:859-547-1245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY730088261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY86000437Medicaid
KY9373101Medicare ID - Type Unspecified