Basic Information
| Provider Information | |||||||||
| NPI: | 1982646725 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLE | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | KEVIN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11995 SINGLETREE LN STE 500 | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553445349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525951301 | ||||||||
| FaxNumber: | 6122944903 | ||||||||
| Practice Location | |||||||||
| Address1: | 1105 EARL FRYE BLVD | ||||||||
| Address2: | |||||||||
| City: | AMORY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388215500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525951100 | ||||||||
| FaxNumber: | 6122944903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 03/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 15524 | MS | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 009949330 | 05 | AL | MEDICAID | 00123929 | 05 | MS | MEDICAID | 300117868 | 01 | MS | RAILROAD MEDICARE | OTHER | P00968040 | 01 | MS | RR MCR | OTHER |