Provider Demographics
NPI:1679877575
Name:BRIDGETON IMAGING, L.L.C.
Entity Type:Organization
Organization Name:BRIDGETON IMAGING, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP OF OUTPATIENT SERVICES, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BURTNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-893-2153
Mailing Address - Street 1:12121 SAINT CHARLES ROCK RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2602
Mailing Address - Country:US
Mailing Address - Phone:314-291-5050
Mailing Address - Fax:314-291-8209
Practice Address - Street 1:12121 SAINT CHARLES ROCK RD
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2602
Practice Address - Country:US
Practice Address - Phone:314-291-5050
Practice Address - Fax:314-291-8209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty