Basic Information
Provider Information | |||||||||
NPI: | 1093094989 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TOMBALL MRI, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AMERICAN HEALTH IMAGING OF TOMBALL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 746530 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303746530 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8772759077 | ||||||||
FaxNumber: | 7209740370 | ||||||||
Practice Location | |||||||||
Address1: | 425 HOLDERRIETH BLVD | ||||||||
Address2: | SUITE 104 | ||||||||
City: | TOMBALL | ||||||||
State: | TX | ||||||||
PostalCode: | 773754543 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2812078800 | ||||||||
FaxNumber: | 2812078999 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2011 | ||||||||
LastUpdateDate: | 11/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LUTZ | ||||||||
AuthorizedOfficialFirstName: | JANE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER OF CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 7043625391 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) | 293D00000X |   |   | N |   | Laboratories | Physiological Laboratory |   | 261QR0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.