Provider Demographics
NPI:1083878284
Name:KENNETT RADIOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:KENNETT RADIOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEACHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-888-8424
Mailing Address - Street 1:1231 1ST ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-2527
Mailing Address - Country:US
Mailing Address - Phone:573-888-8424
Mailing Address - Fax:573-888-2715
Practice Address - Street 1:1301 1ST ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-2525
Practice Address - Country:US
Practice Address - Phone:573-888-8424
Practice Address - Fax:573-888-2715
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNETT HMA PHYSICIAN MANAGEMENT, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2G952085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500451901Medicaid
MO500451901Medicaid