Basic Information
| Provider Information | |||||||||
| NPI: | 1609859511 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILLENNIUM RADIOLOGY ASSOCIATES, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5620 SOUTHWYCK BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 29000 CENTER RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441455293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404146046 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 01/26/2011 | ||||||||
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| AuthorizedOfficialLastName: | DONICH | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4404146046 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2185951 | 05 | OH | MEDICAID | 2183659 | 05 | OH | MEDICAID |