Provider Demographics
NPI:1740224419
Name:CINCINNATI PET SCAN, LLC
Entity Type:Organization
Organization Name:CINCINNATI PET SCAN, LLC
Other - Org Name:NORTHERN KY PET SCAN, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-791-9959
Mailing Address - Street 1:5053 WOOSTER RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45226-2326
Mailing Address - Country:US
Mailing Address - Phone:513-751-2145
Mailing Address - Fax:513-751-2138
Practice Address - Street 1:651 CENTRE VIEW BLVD
Practice Address - Street 2:
Practice Address - City:CRESVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-547-1240
Practice Address - Fax:859-547-1245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY86000437Medicaid
KY86000437Medicaid