1902975386 NPI number — MIDWEST MEDICAL IMAGING CENTER INC

Table of content: (NPI 1902975386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902975386 NPI number — MIDWEST MEDICAL IMAGING CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST MEDICAL IMAGING CENTER INC
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:
1902975386
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1715 DEER TRACKS TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63131-1839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-821-5600
Provider Business Mailing Address Fax Number:
314-821-2189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MIDWEST MEDICAL IMAGING CENTER
Provider Second Line Business Practice Location Address:
6901 NORTH 72ND STREET
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-572-3131
Provider Business Practice Location Address Fax Number:
402-572-3661
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FORREST
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
402-572-3131

Provider Taxonomy Codes

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

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

  • Identifier: 0231183 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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