1043213077 NPI number — KING'S MEDICAL IMAGING AT WATERMARK, LLC

Table of content: (NPI 1043213077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043213077 NPI number — KING'S MEDICAL IMAGING AT WATERMARK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KING'S MEDICAL IMAGING AT WATERMARK, LLC
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:
Provider Other Organization Name Type Code:
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:
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NPI Number Information

NPI Number:
1043213077
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1894 GEORGETOWN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUDSON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44236-4058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-653-3968
Provider Business Mailing Address Fax Number:
330-656-1660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1680 WATERMARK DR
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43215-1034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-485-1804
Provider Business Practice Location Address Fax Number:
614-485-1321
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COYNE
Authorized Official First Name:
V.
Authorized Official Middle Name:
RENAE
Authorized Official Title or Position:
DIRECTOR OF BILLING
Authorized Official Telephone Number:
330-653-3968

Provider Taxonomy Codes

  • Taxonomy code: 293D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2320698 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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