Provider Demographics
NPI:1346220662
Name:CRYSTAL CLEAR IMAGING, LLC
Entity Type:Organization
Organization Name:CRYSTAL CLEAR IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:OSBORN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:937-398-0500
Mailing Address - Street 1:PO BOX 951015
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0005
Mailing Address - Country:US
Mailing Address - Phone:866-917-3597
Mailing Address - Fax:
Practice Address - Street 1:2100 EMMANUEL WAY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502-7217
Practice Address - Country:US
Practice Address - Phone:937-398-0500
Practice Address - Fax:937-398-0370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-20
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000232727OtherANTHEM
OH2364249Medicaid
OH2364249Medicaid