Healthcare Provider Details

I. General information

NPI: 1255430054
Provider Name (Legal Business Name): DIAGNOSTIC RADIOLOGY OF LONDON PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 WALMART PLAZA DR UNIT 4
MONTICELLO KY
42633-7907
US

IV. Provider business mailing address

75 WALMART PLAZA DR UNIT 4
MONTICELLO KY
42633-7907
US

V. Phone/Fax

Practice location:
  • Phone: 606-340-0009
  • Fax: 606-340-0113
Mailing address:
  • Phone: 606-340-0009
  • Fax: 606-340-0113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number33556
License Number StateKY

VIII. Authorized Official

Name: MS. MARY JO SHRUM
Title or Position: FACILITY DIRECTOR
Credential:
Phone: 606-340-0009