Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 2085R0202X | Radiology | Diagnostic Radiology | | | No |
| 2 | 293D00000X | Physiological Laboratory | | | | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 127935 | OTHER | VIRGINIA | SOUTHERN HEALTH |
| 2 | 7817 | OTHER | MISSOURI | COVENTRY HEALTHCARE OF KS |
| 3 | 3010968 | OTHER | TENNESSEE | BCBS OF TN |
| 4 | 194843 | OTHER | VIRGINIA | ANTHEM BCBS OF VA |
| 5 | P00093878 | OTHER | | RAILROAD MEDICARE |
| 6 | 200263800A | MEDICAID | KANSAS | |
| 7 | 3791095 | MEDICAID | TENNESSEE | |
| 8 | 010157188 | MEDICAID | VIRGINIA | |
| 9 | 043260 | OTHER | MISSOURI | FAMILY HEALTH PARTNERS |
| 10 | 146796 | OTHER | KANSAS | UNICARE OF KS |
| 11 | 314335 | OTHER | PENNSYLVANIA | HIGHMARK BCBS OF PA |
| 12 | 718741408 | MEDICAID | MISSOURI | |
| 13 | 98397 | OTHER | VIRGINIA | OPTIMA SENTARA |
| 14 | 01063104 | OTHER | TENNESSEE | AMERIGROUP |
| 15 | 060A117 | OTHER | TENNESSEE | HEALTHSPRING |
