1356309306 NPI number — NORTHEAST MISSOURI IMAGING ASSOCIATES, INC.

Table of content: (NPI 1356309306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356309306 NPI number — NORTHEAST MISSOURI IMAGING ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST MISSOURI IMAGING ASSOCIATES, 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:
1356309306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 861
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HANNIBAL
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63401-0861
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-221-7870
Provider Business Mailing Address Fax Number:
573-221-9323

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6000 HOSPITAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HANNIBAL
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-221-7870
Provider Business Practice Location Address Fax Number:
573-221-9323
Provider Enumeration Date:
05/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SELLE
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
573-221-7870

Provider Taxonomy Codes

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

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

  • Identifier: 1040 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 137441 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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