Provider Demographics
NPI:1902049513
Name:CENTRAL KENTUCKY RADIOLOGY
Entity Type:Organization
Organization Name:CENTRAL KENTUCKY RADIOLOGY
Other - Org Name:DANVILLE DIAGNOSTIC CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:K
Authorized Official - Last Name:KOSTELIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-219-0542
Mailing Address - Street 1:1218 S BROADWAY
Mailing Address - Street 2:STE 310
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2759
Mailing Address - Country:US
Mailing Address - Phone:859-219-0542
Mailing Address - Fax:859-219-9433
Practice Address - Street 1:124 DANIEL DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2527
Practice Address - Country:US
Practice Address - Phone:859-936-9974
Practice Address - Fax:859-936-0973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000061387OtherANTHEM
KY65931644Medicaid
KY000000061387OtherANTHEM