Provider Demographics
NPI:1821094178
Name:ANCILLARY MEDICAL CONSULTANTS, LLC
Entity Type:Organization
Organization Name:ANCILLARY MEDICAL CONSULTANTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ROB
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-491-1490
Mailing Address - Street 1:4197 FULTON DR NW
Mailing Address - Street 2:STE C
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2819
Mailing Address - Country:US
Mailing Address - Phone:330-491-1490
Mailing Address - Fax:330-491-1466
Practice Address - Street 1:303 S NAPPANEE ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2066
Practice Address - Country:US
Practice Address - Phone:574-296-3200
Practice Address - Fax:574-296-3936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed TomographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid
IL209823Medicare PIN