Provider Demographics
NPI:1780642249
Name:POLK COUNTY RADIOLOGY LLC
Entity Type:Organization
Organization Name:POLK COUNTY RADIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:REBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-328-6446
Mailing Address - Street 1:PO BOX 802758
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-0001
Mailing Address - Country:US
Mailing Address - Phone:314-645-4900
Mailing Address - Fax:314-645-6548
Practice Address - Street 1:1500 N OAKLAND AVE
Practice Address - Street 2:DEPT. OF RADIOLOGY
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-3011
Practice Address - Country:US
Practice Address - Phone:417-326-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO503989600Medicaid
MO110449OtherBCBS
MO503989600Medicaid