Basic Information
| Provider Information | |||||||||
| NPI: | 1164622965 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THERAPEUTIC AND DIAGNOSTIC IMAGING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1836 LACKLAND HILL PKWY | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631463572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149890300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9930 WATSON ROAD | ||||||||
| Address2: | |||||||||
| City: | CRESTWOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149848827 | ||||||||
| FaxNumber: | 3146271100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2007 | ||||||||
| LastUpdateDate: | 12/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | LANDGRAF | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3149848827 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 507429306 | 05 | MO | MEDICAID |