Basic Information
Provider Information | |||||||||
NPI: | 1497791321 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. LUKES CENTER FOR DIAGNOSTIC IMAGING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
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Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 790120 | ||||||||
Address2: |   | ||||||||
City: | ST. LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631790120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9525428553 | ||||||||
FaxNumber: | 9525136880 | ||||||||
Practice Location | |||||||||
Address1: | 11605 STUDT AVENUE | ||||||||
Address2: | STE 107 | ||||||||
City: | CREVE COEUR | ||||||||
State: | MO | ||||||||
PostalCode: | 63141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3148727460 | ||||||||
FaxNumber: | 3148727495 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JACOBSEN | ||||||||
AuthorizedOfficialFirstName: | DONALD | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICER ON THE BOARD SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 9525436500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.