Basic Information
| Provider Information | |||||||||
| NPI: | 1679632970 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KILLIAN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 66971 | ||||||||
| Address2: | MID AMERICA RADIOLOGY SC | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631666971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034650401 | ||||||||
| FaxNumber: | 3034042317 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N PLEASANT AVE | ||||||||
| Address2: | RADIOLOGY DEPT | ||||||||
| City: | CENTRALIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628013056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184368000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 09/09/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 036084846 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00357284 | 01 | IL | MEDICARE RAILROAD | OTHER | 036084846-1 | 05 | IL | MEDICAID |