1104884881 NPI number — MISSOURI IMAGING, INC

Table of content: (NPI 1104884881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104884881 NPI number — MISSOURI IMAGING, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSOURI IMAGING, 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:
6
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:
1104884881
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 934995
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31193-4995
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-659-1211
Provider Business Mailing Address Fax Number:
336-774-1751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5905 MEXICO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PETERS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63376-1613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-498-2900
Provider Business Practice Location Address Fax Number:
636-498-2904
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHAEFER
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
770-300-0101

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , 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: 7495351 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 610049401 . This is a "DOL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 717328009 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470000936 . This is a "MEDICARE RR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 199688 . This is a "BC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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