Basic Information
| Provider Information | |||||||||
| NPI: | 1417157595 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STURDY RADIOLOGY ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1849 | ||||||||
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| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042411849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077842554 | ||||||||
| FaxNumber: | 2077775363 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 PARK STREET | ||||||||
| Address2: | |||||||||
| City: | ATTLEBORO | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027033143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5082367750 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2007 | ||||||||
| LastUpdateDate: | 04/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | KAPLAN | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5082367750 | ||||||||
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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 | 2085N0904X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0204X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | MA | MEDICAID | 11078164/A | 05 | MA | MEDICAID | PENDING | 01 | MA | BCBS | OTHER | 9790764 | 05 | MA | MEDICAID |