Basic Information
| Provider Information | |||||||||
| NPI: | 1285613141 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPRINGFIELD RADIOLOGY ASSOCIATES, PC | ||||||||
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| OtherOrganizationName: | IMAGING CONSULTANTS OF KENTUCKY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3125 | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370433125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9316475034 | ||||||||
| FaxNumber: | 9315526663 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 PARK STREET | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707966500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 09/16/2013 | ||||||||
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| AuthorizedOfficialLastName: | BRANNICK | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9316475034 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 000000269735 | 01 | KY | ANTHEM BCBS | OTHER | 4042327 | 01 | TN | BCBS OF TN | OTHER | CJ8639 | 01 | TN | RR MEDICARE | OTHER | 3375149 | 05 | TN | MEDICAID | DO0012 | 01 | KY | RR MEDICARE | OTHER | 020289899 | 01 | DEPT. OF LABOR | OTHER | 65940595 | 05 | KY | MEDICAID | 7916327 | 01 | AETNA | OTHER |