Provider Demographics
NPI:1417016114
Name:HANNIBAL MOBILE DIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:HANNIBAL MOBILE DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
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 1:2910 ST. MARY'S AVE.
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401
Mailing Address - Country:US
Mailing Address - Phone:573-221-7870
Mailing Address - Fax:573-221-9323
Practice Address - Street 1:2910 ST. MARY'S AVE.
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:2006-12-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00126139OtherRAILROAD MEDICARE
IL211414Medicare ID - Type Unspecified