1902049513 NPI number — CENTRAL KENTUCKY RADIOLOGY

Table of content: (NPI 1902049513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902049513 NPI number — CENTRAL KENTUCKY RADIOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL KENTUCKY RADIOLOGY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DANVILLE DIAGNOSTIC CENTER
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902049513
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1218 S BROADWAY
Provider Second Line Business Mailing Address:
STE 310
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40504-2759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-219-0542
Provider Business Mailing Address Fax Number:
859-219-9433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 DANIEL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40422-2527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-936-9974
Provider Business Practice Location Address Fax Number:
859-936-0973
Provider Enumeration Date:
04/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KOSTELIC
Authorized Official First Name:
JON
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
859-219-0542

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000061387 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 65931644 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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