Provider Demographics
NPI:1164514089
Name:PINEVILLE RADIOLOGY ASSOCIATES, PSC
Entity Type:Organization
Organization Name:PINEVILLE RADIOLOGY ASSOCIATES, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANKAR
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKSHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-523-7943
Mailing Address - Street 1:PO BOX 890332
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0332
Mailing Address - Country:US
Mailing Address - Phone:276-523-7938
Mailing Address - Fax:276-523-7028
Practice Address - Street 1:850 RIVERVIEW RD
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-1430
Practice Address - Country:US
Practice Address - Phone:276-523-7938
Practice Address - Fax:276-523-7028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN123862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4404666Medicaid
KY65925133Medicaid
TN4404666Medicaid
KY00942Medicare UPIN