Provider Demographics
NPI:1588654610
Name:PROSCAN RADIOLOGY, LLC
Entity Type:Organization
Organization Name:PROSCAN RADIOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:N
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-281-3400
Mailing Address - Street 1:5400 KENNEDY AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45213-2664
Mailing Address - Country:US
Mailing Address - Phone:513-281-3400
Mailing Address - Fax:513-527-2275
Practice Address - Street 1:5400 KENNEDY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45213-2664
Practice Address - Country:US
Practice Address - Phone:513-281-3400
Practice Address - Fax:513-527-2275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4401045Medicaid
AZ954728Medicaid
WV3810007868Medicaid
NJ0027626Medicaid
NH20002178Medicaid
MS03733011Medicaid
KY65940819Medicaid
SCQPB842Medicaid
OH2552956Medicaid
298152OtherAMERIGROUP
PA1008658800001Medicaid
WA7136252Medicaid
OHPR9332951Medicare ID - Type UnspecifiedMEDICARE