Provider Demographics
NPI:1902403264
Name:PROFESSIONAL PARK DIAGNOSTICS PLLC
Entity Type:Organization
Organization Name:PROFESSIONAL PARK DIAGNOSTICS PLLC
Other - Org Name:PROFESSIONAL PARK DIAGNOSTICS PLLC, , RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:T
Authorized Official - Last Name:MATTINGLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-852-8931
Mailing Address - Street 1:3346 PROFESSIONAL PARK
Mailing Address - Street 2:SUITE A
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4551
Mailing Address - Country:US
Mailing Address - Phone:270-852-8931
Mailing Address - Fax:270-852-8924
Practice Address - Street 1:3346 PROFESSIONAL PARK
Practice Address - Street 2:SUITE A
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-4551
Practice Address - Country:US
Practice Address - Phone:270-228-0405
Practice Address - Fax:270-852-8924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology