Basic Information
| Provider Information | |||||||||
| NPI: | 1699425462 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ERNST RADIOLOGY CLINIC, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12255 DE PAUL DR STE 737 | ||||||||
| Address2: | |||||||||
| City: | BRIDGETON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630442530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148530865 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 GOOD SAMARITAN WAY | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628642402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182424600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2022 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | STADNYK | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3143081700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ERNST RADIOLOGY CLINIC, INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.