Basic Information
| Provider Information | |||||||||
| NPI: | 1659633774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. ELIZABETH PHYSICIANS MAYSVILLE DIAGNOSTIC CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 CHAMBER CENTER DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAKESIDE PARK | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8593445552 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 KENTON STATION DR | ||||||||
| Address2: | SUITE E | ||||||||
| City: | MAYSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410569613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067590073 | ||||||||
| FaxNumber: | 6067590075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2012 | ||||||||
| LastUpdateDate: | 01/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | LOOMIS | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8593443737 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 293D00000X | N | Laboratories | Physiological Laboratory | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 7100225970 | 05 | KY | MEDICAID |