Healthcare Provider Details

I. General information

NPI: 1477593507
Provider Name (Legal Business Name): JAMES HENRY RADACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 LAKE AVE
ASHTABULA OH
44004-4954
US

IV. Provider business mailing address

1719 ALVIN AVE
CLEVELAND OH
44109-4609
US

V. Phone/Fax

Practice location:
  • Phone: 440-997-2262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35048880
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: