Provider Demographics
NPI:1134120454
Name:DES PERES SQUARE IMAGING CENTER LLC
Entity Type:Organization
Organization Name:DES PERES SQUARE IMAGING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:POLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-569-0612
Mailing Address - Street 1:1050 OLD DES PERES RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1873
Mailing Address - Country:US
Mailing Address - Phone:314-569-2412
Mailing Address - Fax:314-569-1655
Practice Address - Street 1:1050 OLD DES PERES RD
Practice Address - Street 2:SUITE 75
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1873
Practice Address - Country:US
Practice Address - Phone:314-569-2412
Practice Address - Fax:314-569-1655
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORTHOPEDIC ASSOCIATES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO168483OtherANTHEM
MO470001747OtherMEDICARE RAILROAD PIN
MO2612904OtherAETNA
MO1601575OtherUNITED HEALTHCARE
MO473861OtherHEALTHLINK
MO2612904OtherAETNA