Basic Information
| Provider Information | |||||||||
| NPI: | 1821013418 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST RADIOLOGICAL ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13209 CORPORATE EXCHANGE DR | ||||||||
| Address2: | |||||||||
| City: | BRIDGETON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630443721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145484715 | ||||||||
| FaxNumber: | 8663025278 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 N BALLAS ROAD | ||||||||
| Address2: | MISSOURI BAPTIST MEDICAL CENTER | ||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145484715 | ||||||||
| FaxNumber: | 3148212180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 04/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | THORNTON | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3145484715 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 12444 | MO | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 508154606 | 05 | MO | MEDICAID | 508154606 | 01 | IL | MCAID | OTHER | 90000352 | 01 | BLUE SHIELD | OTHER |