Healthcare Provider Details

I. General information

NPI: 1023033784
Provider Name (Legal Business Name): ST LUKES CENTER FOR DIAGNOSTIC IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 NORTH BALLAS ROAD SUITE 270
ST LOUIS MO
63141
US

IV. Provider business mailing address

PO BOX 790120
SAINT LOUIS MO
63179-0120
US

V. Phone/Fax

Practice location:
  • Phone: 952-542-8553
  • Fax: 952-513-6880
Mailing address:
  • Phone: 952-542-8553
  • Fax: 952-513-6880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DONALD D JACOBSEN
Title or Position: OFFICER ON THE BOARD SECRETARY
Credential:
Phone: 952-543-6500