Provider Demographics
NPI:1124236740
Name:KENTUCKIANA RADIOLOGY SERVICES, INC
Entity type:Organization
Organization Name:KENTUCKIANA RADIOLOGY SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-876-6644
Mailing Address - Street 1:PO BOX 4489
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47131-4489
Mailing Address - Country:US
Mailing Address - Phone:502-363-1202
Mailing Address - Fax:812-246-4063
Practice Address - Street 1:858 S PENN AVE
Practice Address - Street 2:
Practice Address - City:SELLERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47172-1627
Practice Address - Country:US
Practice Address - Phone:502-363-1202
Practice Address - Fax:812-246-4063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY720043261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY86011061Medicaid
IN100406310AMedicaid
KY86011061Medicaid
IN100406310AMedicaid
KY7000701Medicare ID - Type Unspecified