Basic Information
| Provider Information | |||||||||
| NPI: | 1265423693 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | M&S RADIOLOGY ASSOCIATES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2947 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782992947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108920228 | ||||||||
| FaxNumber: | 2104550169 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 CAMDEN ST | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782152012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108920228 | ||||||||
| FaxNumber: | 2104550169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 02/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | FORTENBERRY | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2108920228 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 164588901 | 05 | TX | MEDICAID |