Healthcare Provider Details

I. General information

NPI: 1821013418
Provider Name (Legal Business Name): MIDWEST RADIOLOGICAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 N BALLAS ROAD MISSOURI BAPTIST MEDICAL CENTER
ST LOUIS MO
63131
US

IV. Provider business mailing address

13209 CORPORATE EXCHANGE DR
BRIDGETON MO
63044-3721
US

V. Phone/Fax

Practice location:
  • Phone: 314-548-4715
  • Fax: 314-821-2180
Mailing address:
  • Phone: 314-548-4715
  • Fax: 866-302-5278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number12444
License Number StateMO

VIII. Authorized Official

Name: CHRISTOPHER THORNTON
Title or Position: PRESIDENT
Credential: MD
Phone: 314-548-4715