Provider Demographics
NPI:1417139023
Name:MIDWEST DIAGNOSTIC IMAGING CENTER
Entity Type:Organization
Organization Name:MIDWEST DIAGNOSTIC IMAGING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:BOB
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:866-504-2674
Mailing Address - Street 1:3920 LINDELL BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-3254
Mailing Address - Country:US
Mailing Address - Phone:866-504-2674
Mailing Address - Fax:
Practice Address - Street 1:4120 LINDELL BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2914
Practice Address - Country:US
Practice Address - Phone:866-504-2674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QR0200X, 261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography