Provider Demographics
NPI:1730158734
Name:KENNEBEC VALLEY RADIOLOGY PROFESSIONAL ASSOCIATION
Entity type:Organization
Organization Name:KENNEBEC VALLEY RADIOLOGY PROFESSIONAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MANSIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-622-4231
Mailing Address - Street 1:28 ARSENAL ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5226
Mailing Address - Country:US
Mailing Address - Phone:207-622-4231
Mailing Address - Fax:207-623-1580
Practice Address - Street 1:28 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5226
Practice Address - Country:US
Practice Address - Phone:207-622-4231
Practice Address - Fax:207-623-1580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME101613OtherBC/BS OF MASS
ME0607OtherANTHEM BC/BS OF MAINE
ME106860000Medicaid
ME0062588OtherAETNA
ME0607OtherFEDERAL BC/BS
ME101613OtherBC/BS OF MASS