Basic Information
| Provider Information | |||||||||
| NPI: | 1023016532 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED IMAGING ASSOCIATES PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 633638 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452633638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662870542 | ||||||||
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| Practice Location | |||||||||
| Address1: | 625 JAMES TRIMBLE BLVD | ||||||||
| Address2: | |||||||||
| City: | PAINTSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 412401055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067893511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 03/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | BOND | ||||||||
| AuthorizedOfficialFirstName: | ALLLEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6067893511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 65938193 | 05 | KY | MEDICAID | DA2906 | 01 | RAILROAD MEDICARE | OTHER | 000000244294 | 01 | KY | BC/BS GROUP PIN NUMBER | OTHER |