Provider Demographics
NPI:1841247566
Name:CLINTON RADIOLOGY PSC
Entity type:Organization
Organization Name:CLINTON RADIOLOGY PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:HAVEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-382-9353
Mailing Address - Street 1:PO BOX 865
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-0865
Mailing Address - Country:US
Mailing Address - Phone:513-852-2451
Mailing Address - Fax:
Practice Address - Street 1:610 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2125
Practice Address - Country:US
Practice Address - Phone:937-382-9353
Practice Address - Fax:937-382-6633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000004057OtherANTHEM
OH0455225Medicaid
CF4981OtherMEDICARE RAILROAD
OH0455225Medicaid
CF4981OtherMEDICARE RAILROAD