Basic Information
| Provider Information | |||||||||
| NPI: | 1205872678 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RADOVANOV | ||||||||
| FirstName: | RADMILA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6120 SHADYBROOK ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672081862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162695000 | ||||||||
| FaxNumber: | 3162690404 | ||||||||
| Practice Location | |||||||||
| Address1: | 1323 N A ST | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671524350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203267451 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 09/15/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0415180 | KS | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 052908 | 01 | KS | BCBS | OTHER | 100081330B | 05 | KS | MEDICAID |