Basic Information
| Provider Information | |||||||||
| NPI: | 1205036225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRAN | ||||||||
| FirstName: | MARYANNE | ||||||||
| MiddleName: | THU | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 WALNUT ST | ||||||||
| Address2: | UNIT 1505 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641062134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166793879 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 PEAKWOOD DR STE 5E | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814405158 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2007 | ||||||||
| LastUpdateDate: | 06/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 2012016184 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 04-35815 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | N1189 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200961800B | 05 | KS | MEDICAID |