Provider Demographics
NPI:1962470484
Name:PRO RAD, INC
Entity Type:Organization
Organization Name:PRO RAD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:EWONUS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:419-636-1131
Mailing Address - Street 1:PO BOX 1046
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-1046
Mailing Address - Country:US
Mailing Address - Phone:419-224-5707
Mailing Address - Fax:419-229-0040
Practice Address - Street 1:433 W HIGH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1690
Practice Address - Country:US
Practice Address - Phone:419-636-1131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000167003OtherANTHEM BCBS
OH2151595Medicaid
128014000OtherUS DEPT OF LABOR WORKERS
OH029599900OtherFEDERAL BLACK LUNG
OH=========-01OtherBUREAU OF WORKERS COMP
OH=========002OtherMEDICAL MUTUAL OF OH
OH=========006OtherMEDICAL MUTUAL OF OH
OH000000167003OtherANTHEM BCBS
OH9239021Medicare PIN