Healthcare Provider Details

I. General information

NPI: 1932145828
Provider Name (Legal Business Name): ST LUKES CENTER FOR DIAGNOSTIC IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5551 WINGHAVEN BOULEVARD SUITE 60
OFALLON MO
63368-3618
US

IV. Provider business mailing address

PO BOX 790120
ST LOUIS MO
63179-0120
US

V. Phone/Fax

Practice location:
  • Phone: 636-625-4434
  • Fax: 636-625-4432
Mailing address:
  • Phone: 952-542-8553
  • Fax: 952-513-6880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DONALD D JACOBSEN
Title or Position: OFFICER ON THE BOARD SECRETARY
Credential:
Phone: 952-543-6500