Provider Demographics
NPI:1619961679
Name:ANDERSSEN, J. RONALD (RT)
Entity Type:Individual
Prefix:
First Name:J.
Middle Name:RONALD
Last Name:ANDERSSEN
Suffix:
Gender:M
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14824 CLAYTON RD
Mailing Address - Street 2:SUITE 21
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-7888
Mailing Address - Country:US
Mailing Address - Phone:636-227-6878
Mailing Address - Fax:636-227-7822
Practice Address - Street 1:14824 CLAYTON RD
Practice Address - Street 2:SUITE 21
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-7888
Practice Address - Country:US
Practice Address - Phone:636-227-6878
Practice Address - Fax:636-227-7822
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MONOT REQUIRED IN MO247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist