Basic Information
| Provider Information | |||||||||
| NPI: | 1609975630 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KANAWHA VALLEY RADIOLOGISTS INCORPORATED | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840 | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458020840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8775747116 | ||||||||
| FaxNumber: | 4192232726 | ||||||||
| Practice Location | |||||||||
| Address1: | 4605 MACCORKLE AVE SW | ||||||||
| Address2: | |||||||||
| City: | SOUTH CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253091311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047663600 | ||||||||
| FaxNumber: | 3043434626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 04/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | RODGERS | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3043434625 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | WV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0008099000 | 05 | WV | MEDICAID | 020021700 | 01 | WV | FEDERAL BLACK LUNG | OTHER | 0216288 | 01 | OH | OHIO MEDICAID | OTHER | 5643 | 01 | WV | CARELINK | OTHER | 001709440 | 01 | WV | MT STATE BLUE CROSS GRP # | OTHER | 0060705 | 05 | OH | MEDICAID |