Basic Information
Provider Information | |||||||||
NPI: | 1801843644 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MIDWEST RADIOLOGICAL ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 55 WESTPORT PLZ | ||||||||
Address2: | SUITE 300 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631463109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3145484772 | ||||||||
FaxNumber: | 7706669118 | ||||||||
Practice Location | |||||||||
Address1: | 11133 DUNN RD | ||||||||
Address2: | RADIOLOGY DEPT | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631366119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3143552300 | ||||||||
FaxNumber: | 3148212180 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2006 | ||||||||
LastUpdateDate: | 12/17/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SUMMERS | ||||||||
AuthorizedOfficialFirstName: | MIKE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3148215600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 2006009466 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
No ID Information.