Basic Information
| Provider Information | |||||||||
| NPI: | 1184888638 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JASPER RADIOLOGY ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 512 MAIN ST | ||||||||
| Address2: | 1401 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761023907 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3560 DELAWARE ST STE 209 | ||||||||
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| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777063059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098993684 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2008 | ||||||||
| LastUpdateDate: | 07/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | LANOUX | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 4098993684 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.