Provider Demographics
NPI:1821285479
Name:J. RONALD ANDERSSEN
Entity Type:Organization
Organization Name:J. RONALD ANDERSSEN
Other - Org Name:ANDERSSEN MOBILE X-RAY SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:J.
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:ANDERSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:636-227-6878
Mailing Address - Street 1:14824 CLAYTON RD
Mailing Address - Street 2:SUITE 21
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-7888
Mailing Address - Country:US
Mailing Address - Phone:636-227-6878
Mailing Address - Fax:636-227-7822
Practice Address - Street 1:14824 CLAYTON RD
Practice Address - Street 2:SUITE 21
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-7888
Practice Address - Country:US
Practice Address - Phone:636-227-6878
Practice Address - Fax:636-227-7822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO711752105Medicaid
MO711752105Medicaid