=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295906121
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSSELLVILLE DIAGNOSTIC IMAGING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2008
-----------------------------------------------------
Last Update Date | 11/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1625 NASHVILLE ST
-----------------------------------------------------
City | RUSSELLVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42276-8853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-725-4561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3339
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37043-3339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-647-5034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. TODD M TALMADGE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 270-725-4561
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | MD36221
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------