Provider Demographics
NPI:1295906121
Name:RUSSELLVILLE DIAGNOSTIC IMAGING
Entity type:Organization
Organization Name:RUSSELLVILLE DIAGNOSTIC IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:M
Authorized Official - Last Name:TALMADGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-725-4561
Mailing Address - Street 1:PO BOX 3339
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-3339
Mailing Address - Country:US
Mailing Address - Phone:931-647-5034
Mailing Address - Fax:
Practice Address - Street 1:1625 NASHVILLE ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-8853
Practice Address - Country:US
Practice Address - Phone:270-725-4561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD362212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DN6583OtherRAILROAD MEDICARE
KY7100040150Medicaid
KY000000566896OtherANTHEM BCBS
KY7100040150Medicaid