=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730147737
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MID-AMERICA IMAGING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2006
-----------------------------------------------------
Last Update Date | 05/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1512 N GREEN MOUNT RD
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-624-0100
-----------------------------------------------------
Fax | 618-624-0102
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1512 N GREEN MOUNT RD
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-624-0100
-----------------------------------------------------
Fax | 618-624-0102
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREASURER
-----------------------------------------------------
Name | PAUL M SCHROEDER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 618-624-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------