MEDICARE: MIDWEST DIAGNOSTIC MEDICINE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1013311323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST DIAGNOSTIC MEDICINE, LLC

Provider Business Mailing Address
First Line	:	11905 W FLORISSANT AVE
Second Line	:	SUITE #200
City	:	FLORISSANT
State	:	MO
Zip	:	63033-6778
Country	:	US
Telephone Number	:	855-984-1465
Fax Number	:	855-984-1469

Provider Business Practice Location Address
First Line	:	11905 W FLORISSANT AVE
Second Line	:	SUITE #200
City	:	FLORISSANT
State	:	MO
Zip	:	63033-6778
Country	:	US
Telephone Number	:	855-984-1465
Fax Number	:	855-984-1469

Authorized Official
Title or Position	:	CEO
Name	:	MR. SYED HAIDER
Credential	:
Telephone Number	:	636-284-9012

Provider Enumeration Date	:	10/15/2014
Last Update Date	:	06/05/2015

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