Provider Demographics
NPI:1740247782
Name:RISTAGNO, ROSS L (MD)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:L
Last Name:RISTAGNO
Suffix:
Gender:M
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:PO BOX 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-245-3107
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:DEPT OF RADIOLOGY
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-584-2146
Practice Address - Fax:513-584-0431
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 054404207R00000X, 207RP1001X, 2085R0204X
OH350544042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0651914Medicaid
KY64121551Medicaid
IN1000029970Medicaid
OH4026450OtherAETNA
OH000000480267OtherANTHEM
OHP00341747OtherMEDICARE RAILROAD
OH309372OtherAMERIGROUP
OH4026450OtherAETNA