Provider Demographics
NPI:1902891955
Name:EAST RIDGE INVESTMENTS LLC
Entity Type:Organization
Organization Name:EAST RIDGE INVESTMENTS LLC
Other - Org Name:ST. JOSEPH IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DALAKISHVILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-676-0625
Mailing Address - Street 1:3937 SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3649
Mailing Address - Country:US
Mailing Address - Phone:816-676-0625
Mailing Address - Fax:816-676-0627
Practice Address - Street 1:3937 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3649
Practice Address - Country:US
Practice Address - Phone:816-676-0625
Practice Address - Fax:816-676-0627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO122536OtherCOVENTRY PIN
MO710208802Medicaid
KS200265470AMedicaid
MOP00173170OtherMEDICARE RAILROAD
MO31465011OtherBCBS KC PIN
MO31465011OtherBCBS KC PIN