Basic Information
| Provider Information | |||||||||
| NPI: | 1316006513 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY ASSOICATES OF TARRANT COUNTY PA | ||||||||
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| OtherOrganizationName: | CENTER FOR DIAGNOSTIC IMAGING | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 816 W CANNON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210387 | ||||||||
| FaxNumber: | 4695226889 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 CAMP BOWIE BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761072729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210312 | ||||||||
| FaxNumber: | 8173177033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 09/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | QUERALT | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8173210312 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085U0001X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085B0100X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085P0229X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 121715001 | 05 | TX | MEDICAID |