Provider Demographics
NPI:1417058009
Name:PHYSICIANS DIAGNOSTIC & REHABILITATION CENTER INC
Entity Type:Organization
Organization Name:PHYSICIANS DIAGNOSTIC & REHABILITATION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:IGNAZIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-758-6440
Mailing Address - Street 1:914 TRAILWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5007
Mailing Address - Country:US
Mailing Address - Phone:330-758-6440
Mailing Address - Fax:330-758-6990
Practice Address - Street 1:914 TRAILWOOD DR
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5007
Practice Address - Country:US
Practice Address - Phone:330-758-6440
Practice Address - Fax:330-758-6990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2533111N00000X
OH2426111N00000X
OH34.0020932081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2318030Medicaid
OH2318030Medicaid
OH5297760001Medicare NSC
OH=========-00OtherWORKMEN'S COMPENSATION