Provider Demographics
NPI:1255406062
Name:NORTHERN LIGHTS IMAGING, LLC
Entity type:Organization
Organization Name:NORTHERN LIGHTS IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:N
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-281-3400
Mailing Address - Street 1:3287 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1312
Mailing Address - Country:US
Mailing Address - Phone:740-450-4200
Mailing Address - Fax:740-450-1785
Practice Address - Street 1:3287 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-1312
Practice Address - Country:US
Practice Address - Phone:740-450-4200
Practice Address - Fax:740-450-1785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1274IC2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2735302Medicaid
OH2735302Medicaid