Basic Information
| Provider Information | |||||||||
| NPI: | 1902975386 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDWEST MEDICAL IMAGING CENTER INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1715 DEER TRACKS TRL | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631311839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148215600 | ||||||||
| FaxNumber: | 3148212189 | ||||||||
| Practice Location | |||||||||
| Address1: | MIDWEST MEDICAL IMAGING CENTER | ||||||||
| Address2: | 6901 NORTH 72ND STREET | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025723131 | ||||||||
| FaxNumber: | 4025723661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FORREST | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4025723131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | NE | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0231183 | 05 | IA | MEDICAID |