Provider Demographics
NPI:1821013418
Name:MIDWEST RADIOLOGICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:MIDWEST RADIOLOGICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-548-4715
Mailing Address - Street 1:13209 CORPORATE EXCHANGE DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-3721
Mailing Address - Country:US
Mailing Address - Phone:314-548-4715
Mailing Address - Fax:866-302-5278
Practice Address - Street 1:3015 N BALLAS ROAD
Practice Address - Street 2:MISSOURI BAPTIST MEDICAL CENTER
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131
Practice Address - Country:US
Practice Address - Phone:314-548-4715
Practice Address - Fax:314-821-2180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO124442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO508154606Medicaid
IL508154606OtherMCAID
90000352OtherBLUE SHIELD
ILCD5209Medicare PIN
MO13128Medicare PIN
MOCD5212Medicare PIN
MO000012444Medicare PIN
MO508154606Medicaid
90000352OtherBLUE SHIELD
IL508154606OtherMCAID
MO12444Medicare ID - Type Unspecified
CD5209Medicare PIN
IL375221Medicare PIN
ILCD5213Medicare PIN
IL375220Medicare PIN