Provider Demographics
NPI:1346264439
Name:PROVISION IMAGING OF NORTHEAST OHIO
Entity Type:Organization
Organization Name:PROVISION IMAGING OF NORTHEAST OHIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MATT
Authorized Official - Last Name:TRENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-842-7768
Mailing Address - Street 1:1601 NW EXPRESSWAY
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118
Mailing Address - Country:US
Mailing Address - Phone:405-842-7768
Mailing Address - Fax:405-842-7789
Practice Address - Street 1:29001 CEDAR RD
Practice Address - Street 2:SUITE 104
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-4062
Practice Address - Country:US
Practice Address - Phone:440-449-2001
Practice Address - Fax:409-449-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1090IC261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPRID02041Medicare ID - Type Unspecified