Provider Demographics
NPI:1144276429
Name:YOUNGSTOWN REGIONAL PET SCAN LLC
Entity type:Organization
Organization Name:YOUNGSTOWN REGIONAL PET SCAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLIENT REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:SAGE
Authorized Official - Middle Name:
Authorized Official - Last Name:YARBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-493-9004
Mailing Address - Street 1:P.O. BOX 76757
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-6500
Mailing Address - Country:US
Mailing Address - Phone:800-624-8910
Mailing Address - Fax:
Practice Address - Street 1:850 MCKAY CT
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-5745
Practice Address - Country:US
Practice Address - Phone:330-758-9411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2424200Medicaid
OH2424200Medicaid