MEDICARE: MEDICAL MILE IMAGING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	R4804	MO

General Provider Information

NPI Number	:	1407389596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL MILE IMAGING

Provider Business Mailing Address
First Line	:	3905 E WINDSMORE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65802
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3905 E WINDSMORE DR
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65802
Country	:	US
Telephone Number	:	417-864-8360
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAN T SULLIVAN
Credential	:	MD
Telephone Number	:	417-864-8360

Provider Enumeration Date	:	04/06/2017
Last Update Date	:	04/06/2017

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