Healthcare Provider Details

I. General information

NPI: 1801843644
Provider Name (Legal Business Name): MIDWEST RADIOLOGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11133 DUNN RD RADIOLOGY DEPT
SAINT LOUIS MO
63136-6119
US

IV. Provider business mailing address

55 WESTPORT PLZ SUITE 300
SAINT LOUIS MO
63146-3109
US

V. Phone/Fax

Practice location:
  • Phone: 314-355-2300
  • Fax: 314-821-2180
Mailing address:
  • Phone: 314-548-4772
  • Fax: 770-666-9118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2006009466
License Number StateMO

VIII. Authorized Official

Name: MR. MIKE SUMMERS
Title or Position: MANAGER
Credential:
Phone: 314-821-5600