Basic Information
| Provider Information | |||||||||
| NPI: | 1477593507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RADACK | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | HENRY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1719 ALVIN AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441094609 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2420 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | ASHTABULA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440044954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409972262 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35048880 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 942460636912 | 01 | OH | CARESOURCE | OTHER | 0651861 | 05 | OH | MEDICAID | P00194548 | 01 | OH | MEDICARE TRAVELERS RR-GA | OTHER |