Basic Information
| Provider Information | |||||||||
| NPI: | 1396765509 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAGNOSTIC IMAGING ALLIANCE OF LOUISVILLE PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 234 E GRAY STREET | ||||||||
| Address2: | SUITE 850 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025851735 | ||||||||
| FaxNumber: | 5025831463 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026297601 | ||||||||
| FaxNumber: | 5026297649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 07/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | HIKEN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5026297601 | ||||||||
| 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 | 65922841 | 05 | KY | MEDICAID |