Provider Demographics
NPI:1659633774
Name:ST. ELIZABETH PHYSICIANS MAYSVILLE DIAGNOSTIC CENTER, LLC
Entity Type:Organization
Organization Name:ST. ELIZABETH PHYSICIANS MAYSVILLE DIAGNOSTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOOMIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-344-3737
Mailing Address - Street 1:2300 CHAMBER CENTER DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAKESIDE PARK
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1673
Mailing Address - Country:US
Mailing Address - Phone:859-344-5555
Mailing Address - Fax:859-344-5552
Practice Address - Street 1:910 KENTON STATION DR
Practice Address - Street 2:SUITE E
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-9613
Practice Address - Country:US
Practice Address - Phone:606-759-0073
Practice Address - Fax:606-759-0075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-14
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100225970Medicaid
KYK057431Medicare PIN