Healthcare Provider Details

I. General information

NPI: 1194777169
Provider Name (Legal Business Name): KIRKSVILLE MEDICAL IMAGING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 CRAIG RD SUITE 112
SAINT LOUIS MO
63141-7132
US

IV. Provider business mailing address

130 E LOCKLING ST
BROOKFIELD MO
64628-2337
US

V. Phone/Fax

Practice location:
  • Phone: 314-336-0945
  • Fax: 314-336-0949
Mailing address:
  • Phone: 314-336-0945
  • Fax: 314-336-0949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: PAUL WILLIAMS
Title or Position: PRESIDENT
Credential: DO
Phone: 314-336-0945