Healthcare Provider Details

I. General information

NPI: 1851144539
Provider Name (Legal Business Name): GREATOR MISSOURI IMAGING ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 THOMPSON RD
COOS BAY OR
97420-2125
US

IV. Provider business mailing address

PO BOX 343
REEDSPORT OR
97467-0343
US

V. Phone/Fax

Practice location:
  • Phone: 541-269-8050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: LETICIA BEACHY
Title or Position: DIRECTOR OF CREDENTIALING
Credential:
Phone: 816-844-7885