MEDICARE: METRO DIAGNOSTIC IMAGING, LLC

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	261QR0208X	Mobile Radiology Clinic/Center	62-9106	MN

General Provider Information

NPI Number	:	1952717852
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METRO DIAGNOSTIC IMAGING, LLC

Provider Business Mailing Address
First Line	:	1997 SLOAN PL STE 23
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55117-2051
Country	:	US
Telephone Number	:	651-800-4818
Fax Number	:	651-800-4819

Provider Business Practice Location Address
First Line	:	1997 SLOAN PL STE 23
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55117-2051
Country	:	US
Telephone Number	:	651-800-4818
Fax Number	:	651-800-4819

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WILLIAM J DAVISON JR.
Credential	:	D.C.
Telephone Number	:	651-216-6330

Provider Enumeration Date	:	07/11/2014
Last Update Date	:	09/16/2020

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