=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831282185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAYMOND WILLIAM JACKSON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 OAK ST STERLING MEDICAL ASSOCIATES
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45219-2598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-984-1800
-----------------------------------------------------
Fax | 513-984-4909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 S JULIANA ST
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15522-1736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-623-7279
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | MD026205E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------