Basic Information
| Provider Information | |||||||||
| NPI: | 1073565248 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENTUCKY MEDICAL IMAGING ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 EASTPOINT PKWY | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402234140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027534949 | ||||||||
| FaxNumber: | 5027534950 | ||||||||
| Practice Location | |||||||||
| Address1: | 1210 KY HIGHWAY 36 E | ||||||||
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| City: | CYNTHIANA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410317498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592342300 | ||||||||
| FaxNumber: | 8592353699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 09/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | CRUTCHER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8592290499 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 65904617 | 05 | KY | MEDICAID |