# MIA OF ST CHARLES COUNTY LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Clinical PET of St Charles County
- **Organization subpart:** No

## Provider details

- **NPI number:** 1922093632
- **Authorized official:** MR. STEVEN MICHAEL MCRAE (MANAGING MEMBER)
- **Authorized official phone:** (618) 659-1167

## Contact information

- **Practice address:** 1475 KISKER RD, STE 145, SAINT CHARLES, MO 63304-8781
- **Practice address phone:** (636) 922-5151
- **Practice address fax:** (636) 922-5454
- **Mailing address:** PO BOX 868, EDWARDSVILLE, IL 62025-0868
- **Mailing address phone:** (618) 659-1167
- **Mailing address fax:** (618) 659-1197

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261Q00000X | Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 09/19/2005
- **Last updated:** 08/22/2020