Basic Information
| Provider Information | |||||||||
| NPI: | 1134559826 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BSA AMARILLO DIAGNOSTIC CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BURTON HILLS BLVD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372156293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152953000 | ||||||||
| FaxNumber: | 6152966011 | ||||||||
| Practice Location | |||||||||
| Address1: | 6700 W 9TH AVE | ||||||||
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| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063580200 | ||||||||
| FaxNumber: | 8063565590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2013 | ||||||||
| LastUpdateDate: | 10/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | PETROVICH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP | ||||||||
| AuthorizedOfficialTelephone: | 6152963000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 339696201 | 05 | TX | MEDICAID |