=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679632970
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT J KILLIAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 09/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 N PLEASANT AVE RADIOLOGY DEPT
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62801-3056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-436-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 66971 MID AMERICA RADIOLOGY SC
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63166-6971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-465-0401
-----------------------------------------------------
Fax | 303-404-2317
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 036084846
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------