Basic Information
| Provider Information | |||||||||
| NPI: | 1548265697 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKES REGION IMAGING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 152 LEMAY FERRY RD | ||||||||
| Address2: | STE 201 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631251254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003541088 | ||||||||
| FaxNumber: | 3146314491 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 SKAGGS RD | ||||||||
| Address2: | |||||||||
| City: | BRANSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656162031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173357000 | ||||||||
| FaxNumber: | 3146314491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROSSOW | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 4173357000 | ||||||||
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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 |
No ID Information.