1477731073 NPI number — ST ELIZABETH SOUTHWOODS IMAGING LLC

Table of content: (NPI 1477731073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477731073 NPI number — ST ELIZABETH SOUTHWOODS IMAGING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST ELIZABETH SOUTHWOODS IMAGING LLC
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:
SOUTHWOODS IMAGING CENTER
Provider Other Organization Name Type Code:
3
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:
1477731073
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 DEBARTOLO PL
Provider Second Line Business Mailing Address:
BLDG B
Provider Business Mailing Address City Name:
YOUNGSTOWN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44512-7004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-726-2595
Provider Business Mailing Address Fax Number:
330-726-3249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 DEBARTOLO PL
Provider Second Line Business Practice Location Address:
BLDG B
Provider Business Practice Location Address City Name:
YOUNGSTOWN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44512-7004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-726-2595
Provider Business Practice Location Address Fax Number:
330-726-3249
Provider Enumeration Date:
02/06/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FULCINITI
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
E
Authorized Official Title or Position:
TREASURER
Authorized Official Telephone Number:
330-729-0357

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  0056IC , 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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