Provider Demographics
NPI:1205858099
Name:SOMERSET OUTPATIENT DIAGNOSTIC CENTER
Entity Type:Organization
Organization Name:SOMERSET OUTPATIENT DIAGNOSTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-678-4114
Mailing Address - Street 1:600 BOGLE ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2885
Mailing Address - Country:US
Mailing Address - Phone:606-678-4114
Mailing Address - Fax:606-679-5862
Practice Address - Street 1:600 BOGLE ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2885
Practice Address - Country:US
Practice Address - Phone:606-678-4114
Practice Address - Fax:606-679-5862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYFDA #1692922471M2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471M2300XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMammographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64785512Medicaid
KY64785512Medicaid
KYC69513Medicare UPIN