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General NPI Number Information
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NPI Number | 1134554538
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Entity Type | Organization
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Legal Business Name | ADVANCED MEDICAL GROUP, LLC
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Dates
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Enumeration Date | 09/05/2013
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Last Update Date | 09/05/2013
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Provider Practice Location Address
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Address Line | 311 N KEENE ST
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City | COLUMBIA
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State | MO
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Zip | 65201-6623
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Country | US
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Telephone | 573-442-1788
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Fax | 573-442-1789
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Provider Business Mailing Address
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Address Line | 311 N KEENE ST
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City | COLUMBIA
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State | MO
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Zip | 65201-6623
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | GREG JOHNSON
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Credential |
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Telephone | 573-442-1788
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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