Provider Demographics
NPI:1578036943
Name:LIBERTY PORTABLE X-RAY OHIO LLC
Entity Type:Organization
Organization Name:LIBERTY PORTABLE X-RAY OHIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-607-1700
Mailing Address - Street 1:955 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-1733
Mailing Address - Country:US
Mailing Address - Phone:717-607-1700
Mailing Address - Fax:717-607-1710
Practice Address - Street 1:1430 OAK HARBOR RD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-1025
Practice Address - Country:US
Practice Address - Phone:717-607-1700
Practice Address - Fax:717-607-1710
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTY PORTABLE X-RAY OHIO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-08
Last Update Date:2024-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile