Provider Demographics
NPI:1336289107
Name:MIDWEST RADIOLOGY KENTUCKY LLC
Entity Type:Organization
Organization Name:MIDWEST RADIOLOGY KENTUCKY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GANOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-557-6165
Mailing Address - Street 1:PO BOX 56046
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-0046
Mailing Address - Country:US
Mailing Address - Phone:317-595-6040
Mailing Address - Fax:317-595-6050
Practice Address - Street 1:4500 BOWLING BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5147
Practice Address - Country:US
Practice Address - Phone:317-595-6040
Practice Address - Fax:317-595-6050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY720176261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY86000395Medicaid
KYP00089265OtherRAILROAD MEDICARE
KY7003001Medicare PIN