Healthcare Provider Details

I. General information

NPI: 1659384899
Provider Name (Legal Business Name): MARK J HALSTED MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5655 HUDSON DR STE 210 ARIS RADIOLOGY
HUDSON OH
44236-4455
US

IV. Provider business mailing address

5655 HUDSON DR STE 210 ARIS RADIOLOGY
HUDSON OH
44236-4455
US

V. Phone/Fax

Practice location:
  • Phone: 330-655-1869
  • Fax: 330-655-3828
Mailing address:
  • Phone: 330-655-1869
  • Fax: 330-655-3828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number35077263
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35.077263
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: