Basic Information
| Provider Information | |||||||||
| NPI: | 1740471127 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KO, MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 RIVER RD | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389304030 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1401 RIVER RD | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389304030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6624559595 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 02/07/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | RADIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 6624559595 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KO'S BILLING OFFICE | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 17150 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 09015666 | 05 | MS | MEDICAID |