Provider Demographics
NPI:1902975386
Name:MIDWEST MEDICAL IMAGING CENTER INC
Entity Type:Organization
Organization Name:MIDWEST MEDICAL IMAGING CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:S
Authorized Official - Last Name:FORREST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-572-3131
Mailing Address - Street 1:1715 DEER TRACKS TRL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1839
Mailing Address - Country:US
Mailing Address - Phone:314-821-5600
Mailing Address - Fax:314-821-2189
Practice Address - Street 1:MIDWEST MEDICAL IMAGING CENTER
Practice Address - Street 2:6901 NORTH 72ND STREET
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68122
Practice Address - Country:US
Practice Address - Phone:402-572-3131
Practice Address - Fax:402-572-3661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0231183Medicaid
NE=========00Medicaid
IA0231183Medicaid
NE40363Medicare PIN
NECO4250Medicare PIN