Basic Information
| Provider Information | |||||||||
| NPI: | 1043250301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONGMOOR | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 152 LEMAY FERRY RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631251253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003541088 | ||||||||
| FaxNumber: | 3146314491 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 KENTUCKY AVENUE | ||||||||
| Address2: | |||||||||
| City: | WEST PLAINS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172569111 | ||||||||
| FaxNumber: | 4172575838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 105540 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.