Provider Demographics
NPI:1912080441
Name:PROGRESSIVE WELLNESS IMAGING
Entity Type:Organization
Organization Name:PROGRESSIVE WELLNESS IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-517-1700
Mailing Address - Street 1:7640 SYLVANIA AVE
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-9729
Mailing Address - Country:US
Mailing Address - Phone:419-517-1700
Mailing Address - Fax:417-517-1711
Practice Address - Street 1:7640 SYLVANIA AVE
Practice Address - Street 2:SUITE A-1
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-9729
Practice Address - Country:US
Practice Address - Phone:419-517-1700
Practice Address - Fax:417-517-1711
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSICIANS IMAGING SOLUTIONS II
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-20
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHIOG1038601261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00361454OtherMEDICARE RAILROAD
OH2614648Medicaid
OH1187-ICOtherHEALTH CARE FACILITY LIC
OHID02701Medicare PIN