1346542388 NPI number — MIDWEST DIAGNOSTIC SERVICES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346542388 NPI number — MIDWEST DIAGNOSTIC SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST DIAGNOSTIC SERVICES LLC
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:
1346542388
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4144 LINDELL BLVD
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63108-2927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-875-9101
Provider Business Mailing Address Fax Number:
314-875-9110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4144 LINDELL BLVD
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63108-2927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-875-9101
Provider Business Practice Location Address Fax Number:
314-875-9110
Provider Enumeration Date:
11/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SHAGRAMANOV
Authorized Official First Name:
VLADIMIR
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
314-875-9101

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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