Provider Demographics
NPI:1902941412
Name:PORTABLE RADIOLOGY SERVICES LLC
Entity type:Organization
Organization Name:PORTABLE RADIOLOGY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:OLEAR
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:330-433-0465
Mailing Address - Street 1:8948 KENNEMER CIR NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-8237
Mailing Address - Country:US
Mailing Address - Phone:330-433-0465
Mailing Address - Fax:330-433-0466
Practice Address - Street 1:8948 KENNEMER CIR NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-8237
Practice Address - Country:US
Practice Address - Phone:330-433-0465
Practice Address - Fax:330-433-0466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00235222OtherRAILROAD MEDICARE
OH16-02180OtherEVERCARE
OHA9999OtherHOMETOWN
OH2599880Medicaid
OH000000376207OtherANTHEM
OH3698731Medicare ID - Type UnspecifiedMEDICARE