Basic Information
| Provider Information | |||||||||
| NPI: | 1073595179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY ASSOCIATES OF NORTHERN KENTUCKY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 932163 | ||||||||
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| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441930001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864124000 | ||||||||
| FaxNumber: | 5864124100 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593314369 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 11/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | DORSEY | ||||||||
| AuthorizedOfficialFirstName: | JOSHUA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8593314369 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200973630A | 05 | IN | MEDICAID | 65900888 | 05 | KY | MEDICAID | 0745331 | 05 | OH | MEDICAID | CL9162 | 01 | KY | RRMC | OTHER |