Basic Information
| Provider Information | |||||||||
| NPI: | 1174563670 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID AMERICAN IMAGING, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 BAYVIEW CIRCLE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926602984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005443215 | ||||||||
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| Practice Location | |||||||||
| Address1: | 659 BOULEVARD ST | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446222026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303433311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 12/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | POAN | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP CORPORATE FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9492425321 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0208X | 02220180040 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mobile |
ID Information
| ID | Type | State | Issuer | Description | 000000166606 | 01 | OH | ANTHEM BCBS OF OHIO | OTHER | 2368727 | 05 | OH | MEDICAID | 366270200 | 01 | OH | ACS/US DEPT OF LABOR | OTHER | 47710-0001 | 05 | OH | MEDICAID | 23753 | 01 | OH | MEDFOCUS RADIOLOGY NETWOR | OTHER | 731337 | 05 | OH | MEDICAID |