Provider Demographics
NPI:1275553067
Name:MISSOURI VALLEY RADIOLOGY LLC
Entity Type:Organization
Organization Name:MISSOURI VALLEY RADIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MONFORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-224-3199
Mailing Address - Street 1:1601 N HARRISON AVE STE 1B
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-2376
Mailing Address - Country:US
Mailing Address - Phone:605-945-1371
Mailing Address - Fax:605-945-3237
Practice Address - Street 1:800 E DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-3313
Practice Address - Country:US
Practice Address - Phone:605-224-3199
Practice Address - Fax:605-945-3237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025345700Medicaid
DE5611OtherRAILROAD MEDICARE
SDS101003Medicare PIN