Healthcare Provider Details

I. General information

NPI: 1417139023
Provider Name (Legal Business Name): MIDWEST DIAGNOSTIC IMAGING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 12/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 LINDELL BLVD
SAINT LOUIS MO
63108-2914
US

IV. Provider business mailing address

3920 LINDELL BLVD SUITE 210
SAINT LOUIS MO
63108-3254
US

V. Phone/Fax

Practice location:
  • Phone: 866-504-2674
  • Fax:
Mailing address:
  • Phone: 866-504-2674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number StateMO

VIII. Authorized Official

Name: MR. THOMAS BOB ROSS JR.
Title or Position: PRESIDENT CEO
Credential:
Phone: 866-504-2674