=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487621785
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAGNOSTIC MEDICAL X RA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2006
-----------------------------------------------------
Last Update Date | 10/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8390 TOD AVE
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44512-6366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-726-6010
-----------------------------------------------------
Fax | 330-726-6017
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3257
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44513-3257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-726-6010
-----------------------------------------------------
Fax | 330-726-6017
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ADAM G CROUCH
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 330-726-6010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------