Provider Demographics
NPI:1952423691
Name:MAYSVILLE DIAGNOSTIC CENTER LLC
Entity type:Organization
Organization Name:MAYSVILLE DIAGNOSTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ISHMAEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-759-0073
Mailing Address - Street 1:910 KENTON STATION DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-9658
Mailing Address - Country:US
Mailing Address - Phone:606-759-0073
Mailing Address - Fax:606-759-0075
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:41056-9658
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:2007-04-04
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY730123261QR0200X, 261Q00000X
KY730122261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100029410Medicaid
KYP00458422OtherRR MEDICARE
KY000000555492OtherANTHEM
KYP00458422OtherRR MEDICARE
KY9380101Medicare PIN