=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043348014
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL RADIOLOGY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9825 KENWOOD RD SUITE 105
-----------------------------------------------------
City | BLUE ASH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45242-6251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-872-4500
-----------------------------------------------------
Fax | 513-872-4518
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9825 KENWOOD RD SUITE 105
-----------------------------------------------------
City | BLUE ASH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45242-6251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-872-4500
-----------------------------------------------------
Fax | 513-872-4518
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | THOMAS M MERCHANT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-527-0403
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 316204
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------