Provider Demographics
NPI:1285619189
Name:SOUTH COUNTY PET IMAGING, LLC
Entity type:Organization
Organization Name:SOUTH COUNTY PET IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF RADIOLOGY
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:B
Authorized Official - Last Name:JUDD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-525-1748
Mailing Address - Street 1:PO BOX 843840
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3840
Mailing Address - Country:US
Mailing Address - Phone:314-821-8055
Mailing Address - Fax:314-821-1833
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:314-525-1748
Practice Address - Fax:314-525-1849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
122078OtherGHP
MO154920OtherBCBS
1601756OtherUHC
1601756OtherUHC