Basic Information
| Provider Information | |||||||||
| NPI: | 1841335643 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH CENTRAL RADIOLOGY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32364 | ||||||||
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| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379302364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655316070 | ||||||||
| FaxNumber: | 6087888799 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 NEWCOMB AVE | ||||||||
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| City: | MOUNT VERNON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404562733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062562195 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 06/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | GOMEZ | ||||||||
| AuthorizedOfficialFirstName: | EDUARDO | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MANAGER-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6066779438 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 | 65942880 | 05 | KY | MEDICAID |