Provider Demographics
NPI:1386698470
Name:SOURCE DIAGNOSTICS LLC
Entity type:Organization
Organization Name:SOURCE DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARCHAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-645-4626
Mailing Address - Street 1:5275 NAIMAN PKWY
Mailing Address - Street 2:STE E
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-1029
Mailing Address - Country:US
Mailing Address - Phone:440-645-7822
Mailing Address - Fax:440-542-9482
Practice Address - Street 1:5275 NAIMAN PKWY
Practice Address - Street 2:STE E
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-1029
Practice Address - Country:US
Practice Address - Phone:440-542-1515
Practice Address - Fax:440-542-9482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246W00000X
OHOH03645247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Multi-Specialty
No246W00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2538052Medicaid
OH2538052Medicaid