MEDICARE: DR. JOHN ELLERT CARLSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	35068359	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184735854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN ELLERT CARLSON MD

Provider Business Mailing Address
First Line	:	23625 COMMERCE PARK
Second Line	:	SUITE 204
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-5845
Country	:	US
Telephone Number	:	216-255-5700
Fax Number	:	216-255-5701

Provider Business Practice Location Address
First Line	:	9764 COUNTRY CREEK WAY
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45458-9242
Country	:	US
Telephone Number	:	937-885-3954
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/07/2009

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