MEDICARE: REGIONAL DIAGNOSTICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center	1116IC	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1225IC	OTHER	OH	OH DEPT HEALTH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225026461
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REGIONAL DIAGNOSTICS LLC

Provider Business Mailing Address
First Line	:	4400 RENAISSANCE PKWY
Second Line	:
City	:	WARRENSVILLE HTS.
State	:	OH
Zip	:	44128-5763
Country	:	US
Telephone Number	:	216-464-8484
Fax Number	:	216-468-6021

Provider Business Practice Location Address
First Line	:	19250 E. BAGLEY RD.
Second Line	:
City	:	MIDDLEBURG HTS.
State	:	OH
Zip	:	44130-3314
Country	:	US
Telephone Number	:	440-260-9970
Fax Number	:	440-260-9980

Authorized Official
Title or Position	:	PRESIDENT AND COO
Name	:	MR. RON LEE CLARK
Credential	:
Telephone Number	:	216-464-8484

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	08/28/2007

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