Basic Information
| Provider Information | |||||||||
| NPI: | 1235324104 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RC HASTEDT MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 PELRET PKWY #200 | ||||||||
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| City: | BEREA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402745000 | ||||||||
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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: | 09/13/2007 | ||||||||
| LastUpdateDate: | 05/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4408292572 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 2795239 | 05 | OH | MEDICAID |