Provider Demographics
NPI:1366874414
Name:JACRIC
Entity type:Organization
Organization Name:JACRIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOGES
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:330-629-9400
Mailing Address - Street 1:965 WINDHAM CT
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5088
Mailing Address - Country:US
Mailing Address - Phone:330-629-9400
Mailing Address - Fax:330-629-9441
Practice Address - Street 1:965 WINDHAM CT
Practice Address - Street 2:SUITE 2
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5088
Practice Address - Country:US
Practice Address - Phone:330-629-9400
Practice Address - Fax:330-629-9441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-31
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0704432085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0293865Medicaid
OH0293865Medicaid