1780707877 NPI number — GREAT PLAINS RADIOLOGY 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 1780707877 NPI number — GREAT PLAINS RADIOLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT PLAINS RADIOLOGY 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:
1780707877
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 E CLINTON PL APT 2A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KIRKWOOD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63122-6172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-822-0690
Provider Business Mailing Address Fax Number:
314-842-2972

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12639 OLD TESSON RD
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63128-2786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-842-8655
Provider Business Practice Location Address Fax Number:
314-842-2972
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HABERT
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
RENE
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
314-822-0690

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)





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