Healthcare Provider Details

I. General information

NPI: 1104001833
Provider Name (Legal Business Name): TIMOTHY JACK STANSBURY R.T. (R)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 12/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

57 PEARL DR
HILLSBORO MO
63050-5032
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax:
Mailing address:
  • Phone: 636-797-5983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number376828
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: