Basic Information
| Provider Information | |||||||||
| NPI: | 1396743191 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ENVISION RADIOLOGY OF TEXAS LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | OUTPATIENT DIAGNOSTIC CENTER AT HUNTERS ROW | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 710 HUNTERS ROW CT | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760634001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174537444 | ||||||||
| FaxNumber: | 8174537441 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 HUNTERS ROW CT | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760634001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174537444 | ||||||||
| FaxNumber: | 8174537441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 07/29/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | EVELYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8174537444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | FTX123 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 161429901 | 05 | TX | MEDICAID |