Provider Demographics
NPI:1073605903
Name:FUNCTIONAL IMAGING AND ASSESSMENT OF KENTUCKY PSC
Entity Type:Organization
Organization Name:FUNCTIONAL IMAGING AND ASSESSMENT OF KENTUCKY PSC
Other - Org Name:FUNCTIONAL IMAGING OF KENTUCKY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:A
Authorized Official - Last Name:MUELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:502-897-5181
Mailing Address - Street 1:1015 DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4610
Mailing Address - Country:US
Mailing Address - Phone:502-897-5181
Mailing Address - Fax:502-897-5122
Practice Address - Street 1:1015 DUPONT RD.
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4610
Practice Address - Country:US
Practice Address - Phone:502-897-5181
Practice Address - Fax:502-897-5122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3754111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000203972OtherANTHEM BLUE CROSS BLUE SH
KY000000203972OtherANTHEM BLUE CROSS BLUE SH
KY6102401Medicare ID - Type Unspecified