Provider Demographics
NPI:1255430054
Name:DIAGNOSTIC RADIOLOGY OF LONDON PSC
Entity type:Organization
Organization Name:DIAGNOSTIC RADIOLOGY OF LONDON PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FACILITY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:SHRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-340-0009
Mailing Address - Street 1:75 WALMART PLAZA DR UNIT 4
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-7907
Mailing Address - Country:US
Mailing Address - Phone:606-340-0009
Mailing Address - Fax:606-340-0113
Practice Address - Street 1:75 WALMART PLAZA DR UNIT 4
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-7907
Practice Address - Country:US
Practice Address - Phone:606-340-0009
Practice Address - Fax:606-340-0113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0200X
KY335562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64353568Medicaid
KYDQ4251OtherRAILROAD MEDICARE
KY64353568Medicaid
KY01172Medicare PIN