Healthcare Provider Details

I. General information

NPI: 1740247782
Provider Name (Legal Business Name): ROSS L RISTAGNO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 02/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST DEPT OF RADIOLOGY
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTIALING
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-584-2146
  • Fax: 513-584-0431
Mailing address:
  • Phone: 513-245-3107
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35 054404
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number35 054404
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35054404
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number35 054404
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: