Provider Demographics
NPI:1649201096
Name:PENNYRILE RADIOLOGY, PSC
Entity Type:Organization
Organization Name:PENNYRILE RADIOLOGY, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-885-3414
Mailing Address - Street 1:PO BOX 595
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241-0595
Mailing Address - Country:US
Mailing Address - Phone:270-885-3414
Mailing Address - Fax:270-885-7631
Practice Address - Street 1:215 W 17TH ST
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1911
Practice Address - Country:US
Practice Address - Phone:270-885-3414
Practice Address - Fax:270-885-7631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000057622OtherANTHEM
KY65901829Medicaid
=========OtherEIN
2647Medicare ID - Type Unspecified