=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609975630
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KANAWHA VALLEY RADIOLOGISTS INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2006
-----------------------------------------------------
Last Update Date | 04/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4605 MACCORKLE AVE SW
-----------------------------------------------------
City | SOUTH CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25309-1311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-766-3600
-----------------------------------------------------
Fax | 304-343-4626
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 840
-----------------------------------------------------
City | LIMA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45802-0840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-574-7116
-----------------------------------------------------
Fax | 419-223-2726
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | DANIEL A RODGERS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 304-343-4625
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------