Provider Demographics
NPI:1821310368
Name:STEWARD PET IMAGING LLC
Entity Type:Organization
Organization Name:STEWARD PET IMAGING LLC
Other - Org Name:STEWARD PET IMAGING LLC AT HAWTHORN MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO - MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:GUYON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:617-789-5047
Mailing Address - Street 1:800 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-3487
Mailing Address - Country:US
Mailing Address - Phone:877-877-8455
Mailing Address - Fax:866-927-0079
Practice Address - Street 1:535 FAUNCE CORNER RD
Practice Address - Street 2:
Practice Address - City:DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1242
Practice Address - Country:US
Practice Address - Phone:877-877-8455
Practice Address - Fax:866-927-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-25
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4NNJ261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110073236MMedicaid
MA4NNJOtherDEPT PUBLIC HEALTH STATE LICENSE
MA4NNJOtherDEPT PUBLIC HEALTH STATE LICENSE