=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255601613
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIGH DESERT RADIOLOGY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2012
-----------------------------------------------------
Last Update Date | 03/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3439 SOUTHERN VISTA DR
-----------------------------------------------------
City | KINGMAN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86401-0630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-718-0180
-----------------------------------------------------
Fax | 928-718-0181
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 4148
-----------------------------------------------------
City | KINGMAN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86402-4148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-718-0180
-----------------------------------------------------
Fax | 928-718-0181
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KALE D BODILY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 928-757-0620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | 42974
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 42974
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------