Provider Demographics
NPI:1467763169
Name:PREMIUM DIAGNOSTICS CENTER LLC
Entity Type:Organization
Organization Name:PREMIUM DIAGNOSTICS CENTER LLC
Other - Org Name:WOMEN'S DIAGNOSTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARI
Authorized Official - Middle Name:
Authorized Official - Last Name:DLUGOSZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-930-6020
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-0417
Mailing Address - Country:US
Mailing Address - Phone:440-930-6020
Mailing Address - Fax:
Practice Address - Street 1:5319 HOAG DR
Practice Address - Street 2:
Practice Address - City:SHEFFIELD VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44035-1494
Practice Address - Country:US
Practice Address - Phone:440-930-6020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-28
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2154350Medicaid
OH2154350Medicaid