Healthcare Provider Details

I. General information

NPI: 1720081524
Provider Name (Legal Business Name): MIDWEST RADIOLOGY AND IMAGING PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 08/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 1ST AVE E
SPENCER IA
51301-4342
US

IV. Provider business mailing address

1200 1ST AVE E
SPENCER IA
51301-4342
US

V. Phone/Fax

Practice location:
  • Phone: 712-262-7511
  • Fax: 712-262-3658
Mailing address:
  • Phone: 712-262-7511
  • Fax: 712-262-3658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES ALLEN CROUCH
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 712-262-7511