Basic Information
| Provider Information | |||||||||
| NPI: | 1487659140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL IMAGING ASSOCIATES OF MEXICO MO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 E MONROE ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | MEXICO | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652652852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003541088 | ||||||||
| FaxNumber: | 3148455668 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 E MONROE ST | ||||||||
| Address2: | |||||||||
| City: | MEXICO | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652652919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735825000 | ||||||||
| FaxNumber: | 3148455668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | CYRIAC | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/RADIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 5735828553 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 711517003 | 05 | MO | MEDICAID | 1311 | 01 | MO | BCBS MO PIN | OTHER | 210116 | 01 | MO | HEALTHLINK PIN | OTHER | DE6186 | 01 | MO | MEDICARE RAILROAD | OTHER |