Healthcare Provider Details

I. General information

NPI: 1952423691
Provider Name (Legal Business Name): MAYSVILLE DIAGNOSTIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 KENTON STATION DR SUITE E
MAYSVILLE KY
41056-9658
US

IV. Provider business mailing address

910 KENTON STATION DR SUITE E
MAYSVILLE KY
41056-9658
US

V. Phone/Fax

Practice location:
  • Phone: 606-759-0073
  • Fax: 606-759-0075
Mailing address:
  • Phone: 606-759-0073
  • Fax: 606-759-0075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number730123
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number730122
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number730123
License Number StateKY

VIII. Authorized Official

Name: MRS. DONNA ISHMAEL
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 606-759-0073