Healthcare Provider Details

I. General information

NPI: 1336289107
Provider Name (Legal Business Name): MIDWEST RADIOLOGY KENTUCKY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 BOWLING BLVD STE 100
LOUISVILLE KY
40207-5147
US

IV. Provider business mailing address

PO BOX 56046
INDIANAPOLIS IN
46256-0046
US

V. Phone/Fax

Practice location:
  • Phone: 317-595-6040
  • Fax: 317-595-6050
Mailing address:
  • Phone: 317-595-6040
  • Fax: 317-595-6050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number720176
License Number StateKY

VIII. Authorized Official

Name: STEVEN GANOTE
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 317-557-6165