Provider Demographics
NPI:1073552972
Name:MID-AMERICA RADIOLOGY INC
Entity Type:Organization
Organization Name:MID-AMERICA RADIOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:D
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:660-259-2203
Mailing Address - Street 1:1500 STATE ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:64067-1107
Mailing Address - Country:US
Mailing Address - Phone:660-259-2203
Mailing Address - Fax:660-259-6806
Practice Address - Street 1:1500 STATE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MO
Practice Address - Zip Code:64067-1107
Practice Address - Country:US
Practice Address - Phone:660-259-2203
Practice Address - Fax:660-259-6806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507573509Medicaid
MODH1403OtherRR MEDICARE
MOM440000Medicare PIN