Provider Demographics
NPI:1487621785
Name:DIAGNOSTIC MEDICAL X RA
Entity type:Organization
Organization Name:DIAGNOSTIC MEDICAL X RA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:CROUCH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-726-6010
Mailing Address - Street 1:PO BOX 3257
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44513-3257
Mailing Address - Country:US
Mailing Address - Phone:330-726-6010
Mailing Address - Fax:330-726-6017
Practice Address - Street 1:8390 TOD AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-6366
Practice Address - Country:US
Practice Address - Phone:330-726-6010
Practice Address - Fax:330-726-6017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-06
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0179131Medicaid
OHDISP02671Medicare ID - Type Unspecified