Provider Demographics
NPI:1356309306
Name:NORTHEAST MISSOURI IMAGING ASSOCIATES, INC.
Entity Type:Organization
Organization Name:NORTHEAST MISSOURI IMAGING ASSOCIATES, INC.
Other - Org Name:HANNIBAL IMAGING ASSOCIATES, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-221-7870
Mailing Address - Street 1:PO BOX 861
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-0861
Mailing Address - Country:US
Mailing Address - Phone:573-221-7870
Mailing Address - Fax:573-221-9323
Practice Address - Street 1:6000 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401
Practice Address - Country:US
Practice Address - Phone:573-221-7870
Practice Address - Fax:573-221-9323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1040OtherANTHEM BLUE CROSS
MO137441OtherHEALTHLINK