Provider Demographics
NPI:1104991918
Name:SOUTHTOWNE IMAGING CENTER LLC
Entity type:Organization
Organization Name:SOUTHTOWNE IMAGING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-315-9109
Mailing Address - Street 1:20 SOUTHTOWNE DR
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-5729
Mailing Address - Country:US
Mailing Address - Phone:573-436-6736
Mailing Address - Fax:573-436-7321
Practice Address - Street 1:20 SOUTHTOWNE DR
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-5729
Practice Address - Country:US
Practice Address - Phone:573-436-6736
Practice Address - Fax:573-436-7321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO269801OtherGHP NUMBER
MO710002502Medicaid
MOP00277531OtherRAILROAD MEDICARE NUMBER
MO59787OtherHEALTHCARE USA NUMBER
MO59787OtherHEALTHCARE USA NUMBER
MOP00277531OtherRAILROAD MEDICARE NUMBER
MO269801OtherGHP NUMBER