Provider Demographics
NPI:1609975630
Name:KANAWHA VALLEY RADIOLOGISTS INCORPORATED
Entity Type:Organization
Organization Name:KANAWHA VALLEY RADIOLOGISTS INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-343-4625
Mailing Address - Street 1:PO BOX 840
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-0840
Mailing Address - Country:US
Mailing Address - Phone:877-574-7116
Mailing Address - Fax:419-223-2726
Practice Address - Street 1:4605 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1311
Practice Address - Country:US
Practice Address - Phone:304-766-3600
Practice Address - Fax:304-343-4626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0008099000Medicaid
WV020021700OtherFEDERAL BLACK LUNG
OH0216288OtherOHIO MEDICAID
WV5643OtherCARELINK
WV001709440OtherMT STATE BLUE CROSS GRP #
OH0060705Medicaid
OH=========02OtherOHIO COMPENSATION
WV9053951Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
WV5643OtherCARELINK