Provider Demographics
NPI:1548591266
Name:MEDICAL IMAGING SHELBYVILLE
Entity Type:Organization
Organization Name:MEDICAL IMAGING SHELBYVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MBA
Authorized Official - Phone:502-647-0311
Mailing Address - Street 1:101 STONECREST RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8169
Mailing Address - Country:US
Mailing Address - Phone:502-647-0311
Mailing Address - Fax:502-647-6011
Practice Address - Street 1:101 STONECREST RD
Practice Address - Street 2:SUITE 2
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-8169
Practice Address - Country:US
Practice Address - Phone:502-647-0311
Practice Address - Fax:502-647-6011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty