Provider Demographics
NPI:1265583462
Name:INDEPENDENT IMAGING, LLC
Entity type:Organization
Organization Name:INDEPENDENT IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-821-5600
Mailing Address - Street 1:1715 DEER TRACKS TRL
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1839
Mailing Address - Country:US
Mailing Address - Phone:314-821-5600
Mailing Address - Fax:314-821-2180
Practice Address - Street 1:500 PORTER AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-2365
Practice Address - Country:US
Practice Address - Phone:417-678-7880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC07732782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty