Basic Information
| Provider Information | |||||||||
| NPI: | 1285619189 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH COUNTY PET IMAGING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 843840 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641843840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148218055 | ||||||||
| FaxNumber: | 3148211833 | ||||||||
| Practice Location | |||||||||
| Address1: | 10010 KENNERLY RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145251748 | ||||||||
| FaxNumber: | 3145251849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | JUDD | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF RADIOLOGY | ||||||||
| AuthorizedOfficialTelephone: | 3145251748 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
ID Information
| ID | Type | State | Issuer | Description | 122078 | 01 | GHP | OTHER | 154920 | 01 | MO | BCBS | OTHER | 1601756 | 01 | UHC | OTHER |