Provider Demographics
NPI:1619081940
Name:PROFESSIONAL IMAGING LLC
Entity Type:Organization
Organization Name:PROFESSIONAL IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-324-3728
Mailing Address - Street 1:777 S NEW BALLAS RD LBBY 5
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8721
Mailing Address - Country:US
Mailing Address - Phone:314-743-2000
Mailing Address - Fax:314-743-2005
Practice Address - Street 1:777 S NEW BALLAS RD
Practice Address - Street 2:SUITE 005
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8705
Practice Address - Country:US
Practice Address - Phone:314-743-2000
Practice Address - Fax:314-743-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO198695OtherBCBS
7935693OtherAETNA
686591OtherHEALTHLINK
MO198695OtherBCBS
686591OtherHEALTHLINK