Basic Information
| Provider Information | |||||||||
| NPI: | 1477500585 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST COUNTY RADIOLOGICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11475 OLDE CABIN RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631417129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149918200 | ||||||||
| FaxNumber: | 3149918206 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 S NEW BALLAS RD | ||||||||
| Address2: | DEPT OF RADIOLOGY | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142516031 | ||||||||
| FaxNumber: | 3149918206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | THOMASSON | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3149918200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085P0229X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 207U00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 500055929 | 05 | MO | MEDICAID |