Basic Information
| Provider Information | |||||||||
| NPI: | 1619954138 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAGNOSTIC X-RAY PHYSICIANS, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5129 DIXIE HWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402161727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024478786 | ||||||||
| FaxNumber: | 5024478623 | ||||||||
| Practice Location | |||||||||
| Address1: | 5129 DIXIE HWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024478786 | ||||||||
| FaxNumber: | 5024478623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 04/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | REPISHTI | ||||||||
| AuthorizedOfficialFirstName: | DAREN | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5024478786 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | CC0216 | 01 | KY | RAILROAD MEDICARE | OTHER | 100010390 | 05 | IN | MEDICAID | 65919011 | 05 | KY | MEDICAID |