Provider Demographics
NPI:1851324982
Name:VANTASSEL, PAMELA (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:VANTASSEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23625 COMMERCE PARK
Mailing Address - Street 2:STE. 204
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-255-5700
Mailing Address - Fax:216-255-5701
Practice Address - Street 1:300 N. NARBERTH AVENUE
Practice Address - Street 2:
Practice Address - City:NARBERTH
Practice Address - State:PA
Practice Address - Zip Code:19072-1807
Practice Address - Country:US
Practice Address - Phone:610-667-7855
Practice Address - Fax:866-898-2159
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD071655L2085N0700X, 2085R0202X
SC108072085R0202X
TXG73642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC108074Medicaid
MI1851324982Medicaid
WA8533119Medicaid
PAP00898180OtherRXR MEDICARE
IA1851324982Medicaid
KY64601206Medicaid
OH2916705Medicaid
PA040412YA6CMedicare PIN
PA0404122BG1Medicare PIN
IA1851324982Medicaid
MI1851324982Medicaid
PA040412ZAD3Medicare PIN
WA8533119Medicaid
PA040412ZBG1Medicare PIN
PA040412V8WMedicare PIN