=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275725103
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENHANCED MEDICAL IMAGING OF PERRYSBURG, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2007
-----------------------------------------------------
Last Update Date | 08/14/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13003 ECKEL JUNCTION RD
-----------------------------------------------------
City | PERRYSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43551-1397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-720-5000
-----------------------------------------------------
Fax | 419-720-5012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13003 ECKEL JUNCTION RD
-----------------------------------------------------
City | PERRYSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43551-1397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-720-5000
-----------------------------------------------------
Fax | 419-720-5012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ERIC WNUCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-285-9092
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 293D00000X
-----------------------------------------------------
Taxonomy Name | Physiological Laboratory
-----------------------------------------------------
License Number | 37841C
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------