1821013418 NPI number — MIDWEST RADIOLOGICAL ASSOCIATES PC

Table of content: (NPI 1821013418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821013418 NPI number — MIDWEST RADIOLOGICAL ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST RADIOLOGICAL ASSOCIATES PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821013418
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13209 CORPORATE EXCHANGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIDGETON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63044-3721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-548-4715
Provider Business Mailing Address Fax Number:
866-302-5278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3015 N BALLAS ROAD
Provider Second Line Business Practice Location Address:
MISSOURI BAPTIST MEDICAL CENTER
Provider Business Practice Location Address City Name:
ST LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-548-4715
Provider Business Practice Location Address Fax Number:
314-821-2180
Provider Enumeration Date:
07/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
THORNTON
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
314-548-4715

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  12444 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 508154606 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 508154606 . This is a "MCAID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 90000352 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".