Healthcare Provider Details

I. General information

NPI: 1477500585
Provider Name (Legal Business Name): WEST COUNTY RADIOLOGICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD DEPT OF RADIOLOGY
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

11475 OLDE CABIN RD SUITE 200
SAINT LOUIS MO
63141-7129
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6031
  • Fax: 314-991-8206
Mailing address:
  • Phone: 314-991-8200
  • Fax: 314-991-8206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY L. THOMASSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 314-991-8200