Provider Demographics
NPI:1720081524
Name:MIDWEST RADIOLOGY AND IMAGING PC
Entity Type:Organization
Organization Name:MIDWEST RADIOLOGY AND IMAGING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:CROUCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:712-262-7511
Mailing Address - Street 1:1200 1ST AVE E
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-4342
Mailing Address - Country:US
Mailing Address - Phone:712-262-7511
Mailing Address - Fax:712-262-3658
Practice Address - Street 1:1200 1ST AVE E
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-4342
Practice Address - Country:US
Practice Address - Phone:712-262-7511
Practice Address - Fax:712-262-3658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IACN6278OtherRAILROAD MEDICARE
IACN6278OtherRAILROAD MEDICARE