Provider Demographics
NPI:1962566000
Name:MEDICAL DIAGNOSTIC CENTER ASSOCIATES LP
Entity type:Organization
Organization Name:MEDICAL DIAGNOSTIC CENTER ASSOCIATES LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-513-9851
Mailing Address - Street 1:18640 E 38TH TER S
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-2304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18640 E 38TH TER S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-2304
Practice Address - Country:US
Practice Address - Phone:816-795-8822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No207RM1200XAllopathic & Osteopathic PhysiciansInternal MedicineMagnetic Resonance Imaging (MRI)Group - Single Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9004147Medicare ID - Type Unspecified