Basic Information
| Provider Information | |||||||||
| NPI: | 1518991645 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PURCHASE RADIOLOGY GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 227 | ||||||||
| Address2: | PURCHASE RADIOLOGY GROUP | ||||||||
| City: | BENTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774592290 | ||||||||
| FaxNumber: | 8592232732 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 HOLIDAY LANE | ||||||||
| Address2: | PARKWAY REGIONAL HOSPITAL | ||||||||
| City: | FULTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774592290 | ||||||||
| FaxNumber: | 8592232732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CHANDLER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8592232250 | ||||||||
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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 | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 65904930 | 05 | KY | MEDICAID | 5864 | 01 | KY | BCBS | OTHER |