1124073960 NPI number — DIAGNOSTIC RADIOLOGY SYSTEMS

Table of content: (NPI 1124073960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124073960 NPI number — DIAGNOSTIC RADIOLOGY SYSTEMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIAGNOSTIC RADIOLOGY SYSTEMS
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:
6
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:
1124073960
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:
601 W SHORT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40508-1246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-231-7644
Provider Business Mailing Address Fax Number:
859-233-7644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2425 REGENCY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40503-2948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-275-2100
Provider Business Practice Location Address Fax Number:
859-275-1159
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MANOR
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
859-231-7644

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  730053 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 86030343 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1167041 . This is a "CHA PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1600375 . This is a "UHC PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 5864584 . This is a "AETNA PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000073108 . This is a "ANTHEM PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 6755 . This is a "BGFH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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