1346264439 NPI number — PROVISION IMAGING OF NORTHEAST OHIO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346264439 NPI number — PROVISION IMAGING OF NORTHEAST OHIO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVISION IMAGING OF NORTHEAST OHIO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346264439
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 NW EXPRESSWAY
Provider Second Line Business Mailing Address:
SUITE 1300
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-842-7768
Provider Business Mailing Address Fax Number:
405-842-7789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29001 CEDAR RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
LYNDHURST
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44124-4062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-449-2001
Provider Business Practice Location Address Fax Number:
409-449-2002
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TRENT
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
MATT
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
405-842-7768

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  1090IC , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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