MEDICARE: ST MARYS IMAGING CENTER II

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	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1659868081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST MARYS IMAGING CENTER II

Provider Business Mailing Address
First Line	:	411 SAINT LANDRY ST
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-4623
Country	:	US
Telephone Number	:	337-470-7517
Fax Number	:

Provider Business Practice Location Address
First Line	:	411 SAINT LANDRY ST
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-4623
Country	:	US
Telephone Number	:	337-470-7517
Fax Number	:

Authorized Official
Title or Position	:	VP OF FINANCE
Name	:	MRS. JENNIFER CLOWERS
Credential	:
Telephone Number	:	337-470-2147

Provider Enumeration Date	:	04/20/2018
Last Update Date	:	09/12/2018

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