Basic Information
| Provider Information | |||||||||
| NPI: | 1033142146 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAGNOSTIC IMAGING ASSOCIATES LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13209 CORPORATE EXCHANGE DR | ||||||||
| Address2: | |||||||||
| City: | BRIDGETON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630443721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144718323 | ||||||||
| FaxNumber: | 3145484748 | ||||||||
| Practice Location | |||||||||
| Address1: | 232 S WOODS MILL RD | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144341500 | ||||||||
| FaxNumber: | 3145484748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 06/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | SUMMERS | ||||||||
| AuthorizedOfficialFirstName: | JEANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 3144718323 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 711811208 | 05 | MO | MEDICAID |