Provider Demographics
NPI:1629000971
Name:ERNST RADIOLOGY CLINIC, INC
Entity Type:Organization
Organization Name:ERNST RADIOLOGY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GRESICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-344-6350
Mailing Address - Street 1:12255 DEPAUL DR
Mailing Address - Street 2:STE 737
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2530
Mailing Address - Country:US
Mailing Address - Phone:314-770-9393
Mailing Address - Fax:314-770-9997
Practice Address - Street 1:12303 DEPAUL DR
Practice Address - Street 2:DEPAUL HEALTH CENTER
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-344-6350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO710545609Medicaid
MO000010025Medicare ID - Type Unspecified