Provider Demographics
NPI: | 1356007116 |
---|---|
Name: | USACS CRITICAL CARE MEDICINE SERVICES EAST, LLC |
Entity Type: | Organization |
Organization Name: | USACS CRITICAL CARE MEDICINE SERVICES EAST, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | EXECUTIVE CHAIRMAN |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DOMINIC |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BAGNOLI |
Authorized Official - Suffix: | JR |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 330-994-4409 |
Mailing Address - Street 1: | 4535 DRESSLER RD NW |
Mailing Address - Street 2: | |
Mailing Address - City: | CANTON |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 44718-2545 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 330-994-4409 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 9901 MEDICAL CENTER DR |
Practice Address - Street 2: | |
Practice Address - City: | ROCKVILLE |
Practice Address - State: | MD |
Practice Address - Zip Code: | 20850-3357 |
Practice Address - Country: | US |
Practice Address - Phone: | 330-994-4409 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-11-16 |
Last Update Date: | 2022-04-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | Group - Single Specialty |