Provider Demographics
NPI:1164622965
Name:THERAPEUTIC AND DIAGNOSTIC IMAGING LLC
Entity Type:Organization
Organization Name:THERAPEUTIC AND DIAGNOSTIC IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:LANDGRAF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-984-8827
Mailing Address - Street 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:
Practice Address - Street 1:9930 WATSON ROAD
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63126
Practice Address - Country:US
Practice Address - Phone:314-984-8827
Practice Address - Fax:314-627-1100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507429306Medicaid
MO507429306Medicaid
MO000015406Medicare PIN