Provider Demographics
NPI:1407389596
Name:MEDICAL MILE IMAGING
Entity Type:Organization
Organization Name:MEDICAL MILE IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-864-8360
Mailing Address - Street 1:3905 E WINDSMORE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3905 E WINDSMORE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802
Practice Address - Country:US
Practice Address - Phone:417-864-8360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICAL MILE IMAGING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR48042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA13482Medicare UPIN