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General NPI Number Information
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NPI Number | 1679877575
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Entity Type | Organization
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Legal Business Name | BRIDGETON IMAGING, L.L.C.
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Dates
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Enumeration Date | 01/06/2011
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Last Update Date | 05/26/2016
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Provider Practice Location Address
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Address Line | 12121 SAINT CHARLES ROCK RD
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City | BRIDGETON
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State | MO
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Zip | 63044-2602
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Country | US
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Telephone | 314-291-5050
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Fax | 314-291-8209
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Provider Business Mailing Address
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Address Line | 12121 SAINT CHARLES ROCK RD
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City | BRIDGETON
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State | MO
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Zip | 63044-2602
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Country | US
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Telephone | 314-291-5050
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Fax | 314-291-8209
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Authorized Official
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Title or Position | SVP OF OUTPATIENT SERVICES, TENET
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Name | MR. MICHAEL KYLE BURTNETT
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Credential |
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Telephone | 469-893-2153
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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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