Provider Demographics
NPI:1689616047
Name:MIDWEST REGIONAL IMAGING SERVICES
Entity Type:Organization
Organization Name:MIDWEST REGIONAL IMAGING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-336-0515
Mailing Address - Street 1:1417 S MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1715
Mailing Address - Country:US
Mailing Address - Phone:605-336-0515
Mailing Address - Fax:605-336-2874
Practice Address - Street 1:6001 S SHARON AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5746
Practice Address - Country:US
Practice Address - Phone:605-338-8811
Practice Address - Fax:605-334-9529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD50438174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7200940Medicaid
SD7200940Medicaid