=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437476900
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEARL IMAGING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2010
-----------------------------------------------------
Last Update Date | 03/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4293 VETERANS MEMORIAL PKWY
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-1657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-567-1818
-----------------------------------------------------
Fax | 314-567-3359
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 796017
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63179-6000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-567-1818
-----------------------------------------------------
Fax | 314-567-3359
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | RITA PAU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-567-1818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------