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General NPI Number Information
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NPI Number | 1205234689
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Entity Type | Organization
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Legal Business Name | LITTLE BEAR RADIOLOGY, LLC
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Dates
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Enumeration Date | 12/16/2014
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Last Update Date | 12/16/2014
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Provider Practice Location Address
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Address Line | 1104 E BROADWAY SUITE 205
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City | COLUMBIA
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State | MO
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Zip | 65201-5121
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Country | US
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Telephone | 417-448-3713
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Fax |
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Provider Business Mailing Address
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Address Line | 1104 E BROADWAY SUITE 205
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City | COLUMBIA
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State | MO
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Zip | 65201-5121
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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 | OWNER
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Name | DR. KRAIG LAGE
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Credential | MD
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Telephone | 573-289-8211
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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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